A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Volume of pedal pulses.

Length of capillary refill.

Rhythm of apical pulse.

Degree of skin elasticity.

Answer and Explanation

The Correct Answer is C

Rationale

A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.

B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.

C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.

D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.

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Correct Answer is C

Explanation

Rationale

A. This comment suggests that the client is aware of the correct technique (inhaling and holding breath) but finds it difficult to execute properly. It indicates a partial understanding of the inhaler technique but potential difficulty in coordination.

B. This comment indicates a misunderstanding of the purpose of a rescue inhaler. Rescue inhalers are intended to be used promptly at the onset of symptoms to relieve acute shortness of breath. Delaying use until symptoms are severe may result in inadequate relief and worsening of respiratory distress.

C. This comment suggests that the client may be swallowing the medication instead of inhaling it into the lungs. Inhalers are meant to deliver medication directly into the lungs through inhalation, not swallowing. Swallowing the medication can lead to gastrointestinal side effects like nausea.

D. Shaking the inhaler before use is a correct step to ensure proper dispersion of the medication. This comment indicates the client understands and follows this part of the inhaler technique correctly.

A. Nausea and headache. B. Watery diarrhea. C. Increased fatigue. D. Yellow-tinged sputum.

Correct Answer is B

Explanation

Rationale

A. Nausea and headache are common side effects of linezolid. While they can impact the client's comfort and adherence to treatment, they are generally not considered urgent or life-threatening unless severe or persistent.

B. Watery diarrhea is a significant concern with linezolid therapy, as it can indicate the development of Clostridium difficile infection (CDI) or other types of antibiotic-associated diarrhea. CDI is a severe condition that requires prompt treatment to prevent complications such as dehydration, colitis, and potentially life-threatening outcomes like toxic megacolon.

C. Increased fatigue can be a nonspecific symptom and may result from various factors, including the underlying illness (nosocomial pneumonia), medication side effects, or the stress of hospitalization. While it should be monitored, it is typically not an immediate concern unless accompanied by other concerning symptoms.

D. Yellow-tinged sputum can indicate the presence of infection or inflammation in the respiratory tract, which is relevant in the context of nosocomial pneumonia. It could suggest a worsening of the pneumonia or a new infection. However, it is not typically directly associated with linezolid therapy itself.

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A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is B

Explanation

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