A nurse is caring for a client admitted to the intensive care unit. Assessment findings are:

BP 160/90

HR 100

RR 27

Sp02 89%

Central Venous Pressure (CVP) 18 mmHg

Pulmonary Arterial Wedge Pressure (PAWP) 21 mmHg. Echocardiogram: Ejection Fraction 30%

BNP 1300 pg/mL

What is the nurse's priority action?

Increase IV fluid infusion per protocol.

Lower the head of the clients bed in Trendelenburg position

Document CVP and continue to monitor.

Administer IV diuretic medications.

Answer and Explanation

The Correct Answer is D

A. Increasing IV fluids would exacerbate the client's fluid overload and worsen heart failure symptoms.

B. Trendelenburg positioning is typically used for shock management, but this client’s fluid overload needs to be addressed first.

C. Monitoring is important but does not address the immediate need to manage fluid overload.

D. The client's elevated CVP, PAWP, and BNP levels indicate fluid overload and heart failure with reduced ejection fraction. The priority is to reduce fluid overload by administering IV diuretics, which will help reduce the pressure in the heart and lungs, improving oxygenation and decreasing the risk of pulmonary edema.

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Correct Answer is D

Explanation

A. Although monitoring hemodynamic parameters is important, this option does not address the immediate issue of low preload, as indicated by the low CVP and PAWP, suggesting hypovolemia.

B. Furosemide is a diuretic and would further decrease intravascular volume, which is inappropriate given the signs of hypovolemia.

C. Decreasing IV fluids would exacerbate the low preload and worsen the client's condition by reducing intravascular volume even further.

D. Administering 0.9% Normal Saline @ 150 mL/hr is the most appropriate intervention. The low CVP and PAWP indicate hypovolemia, and increasing fluid administration will help to increase the preload, thereby improving the client's hemodynamic status.

A. An 80-year-old with chronic obstructive pulmonary disease. B. A 78-year-old who had a carotid endarterectomy. C. A 45-year-old who takes an aspirin daily. D. A 50-year-old who is post coronary artery bypass graft surgery.

Correct Answer is A

Explanation

A. Atrial fibrillation (AF) is more common in older adults, particularly those with underlying conditions like chronic obstructive pulmonary disease (COPD). COPD can lead to structural changes in the heart, increasing the risk of AF. The elderly are particularly vulnerable due to age-related heart changes and comorbidities such as lung disease.

B. While carotid endarterectomy is a surgical procedure that can be related to stroke prevention, it is not directly associated with a higher risk of AF compared to COPD.

C. Aspirin is used for its antiplatelet effects, not directly related to the risk of AF.

D. Post coronary artery bypass graft (CABG) surgery increases the risk for arrhythmias, but it is less directly linked to AF than conditions like COPD in an older adult.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation?

Correct Answer is A

Explanation

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