Which clinical manifestation would the nurse use to indicate that the status of an older adult patient (greater than age 75) with chronic heart failure condition is worsening?

Presence of fine tremors

Heart rate 50 per minute

+1 peripheral edema

Increased confusion

Answer and Explanation

The Correct Answer is D

A. Presence of fine tremors: Fine tremors are not a typical sign of worsening heart failure. They may be associated with medications (like bronchodilators or lithium), metabolic issues, or neurologic disorders, but not directly with heart failure decompensation.

B. Heart rate 50 per minute: Bradycardia may be notable, especially in the context of beta-blocker therapy, but a heart rate of 50 bpm in a stable patient is not necessarily a sign of worsening heart failure unless accompanied by symptoms like dizziness or hypotension.

C. +1 peripheral edema: Mild peripheral edema is often chronic and common in older adults with heart failure. It does not reliably indicate worsening status unless there is a significant increase in edema or associated weight gain and pulmonary symptoms.

D. Increased confusion: Older adults are more susceptible to changes in cognitive function due to decreased cardiac output in worsening heart failure. New or worsening confusion in older adults is a key sign of decreased cerebral perfusion and may signal worsening heart failure. It can also indicate hypoxia or electrolyte imbalance, making it a critical finding that warrants immediate evaluation.

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Correct Answer is E

Explanation

A. contact the prescriber to decrease the rate of the D51/2NS during the blood transfusion: There's no need to alter the rate of maintenance fluids unless there's a fluid volume concern. Additionally, decreasing the rate would not address the need for a dedicated blood transfusion line if another lumen is available.

B. stop the D51/2NS, check the client's vitals & notify the prescriber: Stopping necessary fluids without cause may compromise fluid balance. Unless there's a compatibility issue or no other lumen, stopping the infusion is not the safest or most efficient action.

C. Fluids cannot be given through a CVC: Central venous catheters are routinely used for administering fluids, medications, and blood products, especially in critical care settings.

D. Insert a 22 gauge peripheral IV to administer the transfusion: While blood can be given through a peripheral IV, using an existing central venous catheter is safer and more efficient, especially when multiple lumens are available. Inserting a new IV unnecessarily increases infection and complication risks.

E. transfuse the unit of packed red blood cells through a separate lumen of the CVC: This is the safest and most appropriate action. Triple-lumen CVCs allow for simultaneous infusions through separate channels without mixing. Blood should be transfused through a dedicated lumen to avoid incompatibility or dilution by other fluids.

A. Cardiovert in the synchronized mode. B. Defibrillate immediately with a biphasic machine. C. Take a full set of vital signs. D. Initiate cardiopulmonary resuscitation.

Correct Answer is B

Explanation

A. Cardiovert in the synchronized mode: Synchronized cardioversion is used for hemodynamically unstable but conscious patients with rhythms like atrial fibrillation or supraventricular tachycardia. It is not appropriate for a pulseless patient with ventricular fibrillation, as synchronization requires detectable R-waves.

B. Defibrillate immediately with a biphasic machine: The rhythm strip shows ventricular fibrillation (VF) a life-threatening arrhythmia characterized by chaotic, irregular waveform with no identifiable PQRST and no effective cardiac output. The patient is unresponsive and pulseless, making immediate defibrillation the priority action, as per Advanced Cardiac Life Support (ACLS) guidelines.

C. Take a full set of vital signs: The client is already unresponsive and pulseless, making a full set of vitals irrelevant at this moment. Immediate resuscitation efforts, including defibrillation and CPR, take priority.

D. Initiate cardiopulmonary resuscitation: While CPR is a critical part of the algorithm for pulseless rhythms, defibrillation is the first priority in ventricular fibrillation when a defibrillator is available and ready. CPR should be started immediately after the shock if no pulse returns.

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Which clinical manifestation would the nurse use to indicate that the status of an older adult patient (greater than age 75) with chronic heart failure condition is worsening?

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Naxlex Comprehensive Predictor Exams

A client has a triple lumen subclavian central venous catheter (CVC) with D51/2NS infusing through one lumen (port) at 75 mL per hour. The nurse has an order to transfuse one unit of packed red blood cells (PRBCs). The nurse's safest action is to:

Correct Answer is E

Explanation

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Correct Answer is B

Explanation

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Which clinical manifestation would the nurse use to indicate that the status of an older adult patient (greater than age 75) with chronic heart failure condition is worsening?