A nurse is caring for a client at a clinic.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for developing

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due to

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.

Rationale for Correct Choices

• Heart failure: The client’s symptoms bilateral crackles, +3 lower extremity edema, cool limbs with weak pulses, an S3 heart sound, and elevated BNP are classic signs of decompensated heart failure with volume overload and poor perfusion.
• Educate the client about sodium restriction: Sodium contributes to fluid retention and increased cardiac workload. Dietary sodium restriction is crucial in preventing fluid overload, thus reducing exacerbations of heart failure symptoms such as edema and dyspnea.
• Obtain a prescription for a diuretic: Diuretics like furosemide relieve volume overload by promoting fluid excretion. They help decrease pulmonary congestion, improve oxygenation, and reduce peripheral edema in heart failure patients.
• Daily weight: Monitoring weight helps detect subtle changes in fluid balance. A sudden weight gain of 2–3 pounds in 24 hours may signal worsening heart failure and the need for diuretic adjustment.
• Blood pressure: Blood pressure monitoring provides insight into cardiac output and guides medication titration. Both hypertension and hypotension can worsen outcomes in clients with heart failure.

Rationale for Incorrect Choices

• Endocarditis: This condition presents with fever, new or changing murmurs, petechiae, or positive blood cultures. The absence of infection signs and the presence of systemic fluid overload point away from endocarditis.
• Aortic stenosis: Typical signs include exertional dyspnea, syncope, chest pain, and a harsh systolic murmur not crackles, edema, or elevated BNP. This client’s profile better matches heart failure.
• Mitral stenosis: This condition may cause pulmonary congestion but often presents with a diastolic murmur and atrial fibrillation, which are not described here.
• Administer antibiotics as prescribed: Without clinical or laboratory signs of infection (fever, leukocytosis, or positive cultures), antibiotics are not appropriate for heart failure.
• Prepare the client for cardioversion: Cardioversion is used for arrhythmias like atrial fibrillation with rapid ventricular response. The client has a normal apical pulse and no dysrhythmia signs.
• Educate the client about valve replacement: Valve surgery is not indicated unless diagnostic findings confirm severe valvular disease. No murmur or echo data is provided here.
• Skin lesions: These are associated with endocarditis, not heart failure. Findings like Janeway lesions or Osler nodes are not reported in this case.
• Blood cultures: Indicated when bacteremia or endocarditis is suspected. Heart failure without infection signs does not warrant blood cultures.
• Fever: The client is afebrile, making infection less likely. Fever is not a feature of uncomplicated heart failure and does not need monitoring here.

Calculation:

Total volume = 100 mL.

• Convert the infusion time from minutes to hours.

Infusion time = 30 min / 60 min/hr

= 0.5 hr.

• Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hr)

= 100 mL / 0.5 hr

= 200 mL/hr.