A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).
The client’s oxygen saturation level is 85%.
The client is eating less than half of meals
The client’s heart rate is 110 beats per minute.
The client is reading a book.
The client’s blood pressure is 160/90 mmHg.
Correct Answer : A,C,E
The observation(s) by the nurse that require immediate intervention to reduce the likelihood of harm to this client are:
A. The client’s oxygen saturation level is 85%. This is a sign of hypoxemia, which can lead to tissue hypoxia, organ damage, and cardiac arrest. The nurse should administer oxygen therapy and monitor the client’s respiratory status closely.
C. The client’s heart rate is 110 beats per minute. This is a sign of tachycardia, which can indicate worsening heart failure, dehydration, infection, or anxiety. The nurse should assess the client’s fluid balance, vital signs, and symptoms and report any changes to the physician. The nurse should also administer medications as prescribed to control the heart rate and reduce the cardiac workload.
E. The client’s blood pressure is 160/90 mmHg. This is a sign of hypertension, which can increase the risk of stroke, myocardial infarction, and renal failure. The nurse should administer antihypertensive medications as prescribed and monitor the client’s blood pressure and urine output. The nurse should also educate the client on lifestyle modifications to lower blood pressure, such as reducing salt intake, exercising, and managing stress .
The other observations do not require immediate intervention, but they should be addressed as part of the comprehensive nursing care plan for the client with heart failure and COPD. These include:
B. The client is eating less than half of meals. This can indicate poor appetite, nausea, dyspnea, or fatigue, which can affect the client’s nutritional status and energy level. The nurse should encourage the client to eat small, frequent, and balanced meals that are low in sodium, fat, and cholesterol. The nurse should also provide oral hygiene and offer supplements or enteral feeding if needed .
D. The client is reading a book. This can indicate that the client is coping well with the condition and engaging in leisure activities that promote relaxation and mental health. The nurse should praise the client for this positive behavior and provide emotional support and counseling as needed. The nurse should also teach the client about the signs and symptoms of exacerbation and when to seek medical help .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The client being the oldest of their siblings is not a contributing factor related to the development of conduct disorder. Family dynamics such as birth order may have some influence on personality traits, but they are not a primary factor in the development of conduct disorder.
Choice B rationale:
The fact that the client's father lives in the client's home is a family dynamic, but it does not necessarily contribute to the development of conduct disorder. Other factors related to parenting style, communication, and family interactions play a more significant role in the development of conduct disorder.
Choice C rationale:
The client's mother having asthma is a medical condition and not a family dynamic that directly contributes to the development of conduct disorder. Conduct disorder is more closely associated with social, environmental, and psychological factors.
Choice D rationale:
The presence of several siblings in the family dynamic can contribute to the development of conduct disorder. Increased family size can lead to competition for attention and resources, which may affect the child's behavior and interactions. Sibling relationships and family dynamics are crucial in shaping a child's behavior and psychological well-being.
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. Antihypertensive drugs typically work by reducing blood pressure through various mechanisms, such as dilating blood vessels, reducing blood volume, or affecting the heart's workload. They do not increase blood flow to the heart and kidneys.
Choice B rationale:
This is the correct answer. Antihypertensive drugs work by affecting different aspects of the cardiovascular system, such as reducing blood vessel constriction (vasodilation), decreasing blood volume, or slowing the heart rate. By affecting these components, they can lower blood pressure.
Choice C rationale:
This statement is incorrect. Antihypertensive drugs can interact with other medications or supplements, potentially causing adverse effects or drug interactions. It's essential for the client to inform their healthcare provider of all medications and supplements they are taking to ensure safe and effective treatment.
Choice D rationale:
This statement is incorrect. Antihypertensive drugs do not cure hypertension but help control it. Clients need to understand that they will likely need to take these medications long-term to manage their blood pressure effectively.
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