A nurse is caring for a 74-year-old female client who reports experiencing increased shortness of breath.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A blood pressure of 110/70 and heart rate of 90 is within normal limits and does not indicate an immediate complication.
B. Swelling at the insertion site and a cool extremity suggest arterial occlusion or hematoma formation, which is a serious complication requiring immediate intervention. This may indicate impaired blood flow to the limb.
C. Oozing blood from the site may require monitoring and pressure application but is not as concerning as signs of arterial compromise.
D. Not voiding post-procedure can be due to bedrest or IV contrast, but it is not an urgent concern.
Correct Answer is ["B","C","D","E","F"]
Explanation
A. Increased appetite is not a symptom of worsening right-sided heart failure; clients may actually experience nausea or anorexia due to fluid congestion in the gastrointestinal system.
B. Distended neck veins (jugular venous distension) indicate increased venous pressure and systemic congestion, which are signs of worsening right-sided heart failure.
C. Worsening lower extremity edema occurs due to fluid retention and poor venous return, which are hallmark signs of right-sided heart failure.
D. Feeling fatigued is common as the heart struggles to pump blood effectively, leading to decreased oxygen delivery to tissues.
E. Unable to lie flat (orthopnea) is typically associated with left-sided heart failure but can also occur in right-sided failure due to fluid overload and pulmonary congestion.
F. Weight gain >2 lb in 24 hours suggests significant fluid retention and worsening heart failure, requiring prompt medical attention.
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