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A nurse is assisting with the care of a client in an outpatient provider's office.

Exhibits

The nurse should identify that the client is at risk of developing

and may require further .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

The nurse should identify that the client is at risk of developing heart failure and may require further assessment and intervention.

Heart failure is suggested by the progressive decline in vital signs and laboratory results, such as increasing BUN and creatinine levels, which indicate worsening kidney function and can contribute to heart failure. The client’s fatigue, weakness, bilateral edema, and crackles in the lungs are clinical signs consistent with heart failure. The dry, flaky skin and coarse, thinning hair also reflect systemic issues that could be associated with heart failure and poor nutritional status.

The nurse should focus on further assessment to evaluate the severity of heart failure and intervention to manage symptoms, potentially including medication adjustments, fluid management, and additional diagnostic testing. These steps are crucial to addressing the client’s deteriorating condition and preventing further complications.


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Related Questions

Correct Answer is C

Explanation

A. One fingerbreadth of space between the cast and the skin is important to prevent constriction, but diminished pulses suggest compromised blood circulation, which is a higher priority.
B. Muscle spasms are common and can cause discomfort, but diminished pulses indicate a more serious circulation issue.
C. Correct. Diminished pulses suggest reduced blood flow, which is a serious concern and requires immediate attention.
D. Ecchymosis might be related to the cast application, but it's less urgent than compromised circulation.

Correct Answer is C

Explanation

Answer is:Drain the tub water before the client gets out.

Explanation: This is the correct answer because it reduces the risk of slipping and falling for the client, especially if they have limited mobility or balance problems. The other options are incorrect because:

  • Checking on the client every 10 min during the bath is not enough to ensure their safety and comfort.The nurse should check on them more frequently, such as every 5 to 10 minutes, depending on their needs and preferences.
  • Adding bath oil to the water after the client gets into the tub is not a good idea because it can make the water slippery and increase the risk of falling.The nurse should add bath oil to the water before the client gets into the tub, or use a non-slip mat or shower chair.
  • Allowing the client to remain in the bath for 30 min is too long and can cause dehydration, hypothermia, or skin irritation.The nurse should instruct the client to remain in the tub for no longer than 20 min, unless otherwise ordered by a physician.

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