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 B

Explanation

Choice A reason: Administering oxygen supports oxygenation but is not the priority during a seizure, typically brief without sustained hypoxia. Removing objects prevents trauma from tonic-clonic movements, driven by neuronal hyperexcitability, addressing the immediate risk of fractures or head injuries during uncontrolled muscle activity.

Choice B reason: Removing objects prevents injury during a seizure, as tonic-clonic convulsions from excessive neuronal discharges risk trauma like fractures. Ensuring a safe environment addresses the physiological risk of harm from environmental hazards, critical for protecting the client during uncontrolled movements in seizure activity.

Choice C reason: Placing pillows around the head may reduce injury but is less effective than clearing hazards, as seizures involve full-body movements. Pillows may not stay secure during clonic jerking. Removing objects ensures broader safety, minimizing trauma risk across all body areas, making this less immediate.

Choice D reason: Applying restraints is contraindicated, as they risk injury like fractures by resisting forceful neuronal-driven movements. Seizures require safe movement in a clear environment. Removing objects prevents trauma, addressing the physiological need for safety during a seizure, making restraints inappropriate and potentially harmful.

A. Obtain another measurement of the client’s blood pressure. B. Determine what medications the client recently received. C. Administer the antihypertensive medication as prescribed. D. Consult with the PN about the client’s condition at 0800.

Correct Answer is A

Explanation

Choice A reason: Obtaining another blood pressure measurement is critical, as lethargy, pallor, and diaphoresis suggest hypotension or shock, despite the earlier 140/90 reading. This guides safe administration of antihypertensives, preventing harm, per cardiovascular assessment and medication safety protocols in nursing practice.

Choice B reason: Determining recent medications is important but secondary to assessing current blood pressure, as symptoms suggest acute instability. Blood pressure confirms hypotension risk before reviewing drugs, ensuring timely intervention, per cardiovascular assessment and patient safety standards in nursing care.

Choice C reason: Administering antihypertensives without reassessing blood pressure is unsafe, as lethargy, pallor, and diaphoresis indicate possible hypotension. Confirming blood pressure prevents exacerbating instability, per medication safety and cardiovascular monitoring protocols in nursing practice for clients with hypertension.

Choice D reason: Consulting the PN about the 0800 condition delays immediate assessment of current symptoms. Blood pressure measurement addresses acute lethargy, pallor, and diaphoresis, guiding intervention. Consultation is secondary, per prioritization and cardiovascular assessment standards in nursing care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

Correct Answer is B

Explanation

At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

Correct Answer is A

Explanation

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