A client with heart failure is receiving intravenous fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider?

Observe for change in breathing pattern.

Palpate the volume of pedal pulses.

Assess for inflammation of the calves.

Inspect for distention of peripheral veins.

Answer and Explanation

The Correct Answer is A

Choice A reason: Increased JVD and pedal edema indicate fluid overload in heart failure, where reduced cardiac output causes venous congestion. Assessing breathing for dyspnea or crackles detects pulmonary edema, as fluid backs into alveoli, impairing gas exchange. This urgent finding guides interventions like diuretics, critical before reporting.

Choice B reason: Palpating pedal pulses assesses arterial flow, not fluid overload causing JVD and edema, which are venous issues in heart failure. Pulses may be normal despite congestion. Breathing changes indicate pulmonary edema, a life-threatening complication, making this assessment more critical for detecting acute decompensation.

Choice C reason: Assessing calf inflammation may detect thrombosis, a heart failure risk, but JVD and edema suggest fluid overload, not clotting. Breathing changes are more urgent, indicating pulmonary edema from alveolar fluid, requiring immediate intervention to prevent respiratory failure, unlike inflammation, which is less immediate.

Choice D reason: Inspecting peripheral vein distention confirms venous congestion but is less critical than breathing assessment. In heart failure, fluid overload risks pulmonary edema, where alveolar fluid causes dyspnea. Monitoring breathing detects this severe complication, prioritizing intervention to ensure oxygenation over additional venous assessment.

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Correct Answer is A

Explanation

Choice A reason: Yellow purulent drainage indicates wound infection, likely from bacterial proliferation (e.g., Staphylococcus aureus) causing pus. This serious complication risks delayed healing, abscess, or sepsis, necessitating provider notification for cultures, antibiotics, or surgical intervention. Infection disrupts tissue repair, requiring urgent management to prevent systemic spread or wound dehiscence.

Choice B reason: Pink granulation tissue is normal in wound healing, reflecting angiogenesis and fibroblast activity during the proliferative phase. It indicates healthy tissue formation, not requiring notification. Purulent drainage, however, signals infection, a critical issue disrupting healing and risking complications, making it the priority finding for reporting.

Choice C reason: Serosanguineous fluid, a mix of serum and blood, is expected in early surgical wounds as capillaries heal. It does not indicate infection unless excessive. Purulent drainage is more urgent, directly suggesting bacterial infection, which can lead to serious complications like sepsis, requiring immediate provider attention.

Choice D reason: Approximated wound edges indicate proper closure and healing, reducing scarring and infection risk. This positive finding does not warrant notification. Yellow purulent drainage, conversely, signals infection, a critical complication requiring urgent intervention to prevent further tissue damage or systemic infection, making it the priority.

A. Continue the heparin infusion at the current rate. B. Increase the heparin infusion rate by 100 units/hour. C. Stop the heparin infusion and notify the provider. D. Administer protamine sulfate immediately.

Correct Answer is C

Explanation

Choice A reason: Continuing heparin at aPTT 120 seconds is unsafe, as it exceeds the therapeutic range (38–88 seconds), indicating excessive anticoagulation. This risks bleeding, as heparin enhances antithrombin, inhibiting clotting factors. Stopping and notifying the provider prevents hemorrhage, making continuation dangerous for this DVT client.

Choice B reason: Increasing heparin is contraindicated with aPTT 120 seconds, far above therapeutic (38–88 seconds). Excessive anticoagulation from heparin’s antithrombin activation heightens bleeding risk. Stopping the infusion and notifying the provider corrects over-anticoagulation, preventing complications like hematoma, making an increase harmful and inappropriate.

Choice C reason: Stopping heparin and notifying the provider is critical at aPTT 120 seconds, indicating over-anticoagulation. Heparin’s inhibition of clotting factors increases bleeding risk in DVT treatment. Halting infusion prevents hemorrhage, and provider notification ensures dose adjustment or reversal, addressing the pathophysiological risk effectively and promptly.

Choice D reason: Administering protamine sulfate reverses heparin but requires provider order, as aPTT 120 seconds indicates high bleeding risk. Stopping infusion first prevents further anticoagulation, and notifying the provider ensures guided reversal, avoiding premature protamine use, which risks anaphylaxis or thrombosis, making this less immediate.

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A client with heart failure is receiving intravenous fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider?

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