A nurse is caring for a 74-year-old female client who reports experiencing increased shortness of breath.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Worsening of congestive heart failure is suggested by symptoms including labored breathing, coarse crackles, jugular vein distention (JVD), cool/clammy skin, and low oxygen saturation. These findings indicate pulmonary congestion due to fluid overload.
Applying O₂ at 6L/min helps improve oxygenation and alleviate respiratory distress. Lower-flow oxygen (such as 2L/min) may not be sufficient in acute heart failure exacerbation.
Monitoring respiratory rate is essential to track breathing effort and response to treatment.
Monitoring oxygen saturation helps assess oxygenation status and effectiveness of interventions.
Smoking cessation is important for long-term lung and cardiovascular health but does not address the acute issue.
WBC count and temperature are more relevant to infections like pneumonia rather than acute heart failure.

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Correct Answer is C

Explanation

A. A new systolic murmur is more indicative of valvular dysfunction or a septal defect rather than pericardial effusion.
B. Diminished breath sounds may be associated with atelectasis or pleural effusion but are not a hallmark finding of pericardial effusion.
C. Diminished heart sounds occur due to fluid accumulation in the pericardial sac, which muffles heart tones and is a key sign of pericardial effusion.
D. Increased blood pressure is not characteristic of pericardial effusion. Instead, pericardial effusion can lead to cardiac tamponade, which typically causes hypotension.

A. Reduction of blood pressure to normal over a period of days B. Reduce the blood pressure to normal over a period of hours. C. Reduction of blood pressure by 50% in the first hour. D. Reduce blood pressure until the patient is asymptomatic.

Correct Answer is A

Explanation

A. In a hypertensive emergency, the goal is to reduce blood pressure gradually over 24 to 48 hours to prevent organ damage while avoiding excessive drops that could cause ischemia.
B. Rapid reduction of blood pressure over a few hours can lead to organ hypoperfusion and ischemic complications, such as stroke or acute kidney injury.
C. A 50% reduction in the first hour is too aggressive and may result in severe adverse effects such as cerebral or myocardial ischemia. The recommended initial reduction is no more than 25% in the first hour.
D. Treating hypertension based solely on symptoms is inappropriate, as some patients may be asymptomatic despite dangerously high blood pressure. The focus is on preventing target organ damage.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in a critical care unit who is 4 hours post-operative coronary artery bypass surgery. The nurse performs the reassessment and suspects the client may be developing a pericardial effusion. What assessment findings would the nurse note in this case?

Correct Answer is C

Explanation

A nurse is caring for a client admitted with hypertensive emergency. The nurse is aware the treatment goals for the patient include which of the following?

Correct Answer is A

Explanation

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