A nurse is caring for a client who has heart failure.
Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Fluid volume deficit
The client is receiving Furosemide (a diuretic) at a significant dose (80 mg IV three times per day). This medication promotes diuresis to reduce fluid overload in heart failure. The client's weight decreased from 97.5 kg on admission to 90.7 kg on Day 2, indicating a fluid loss of approximately 6.8 kg (about 15 pounds). This substantial weight loss suggests a risk for fluid volume deficit, which can lead to hypovolemia and potential complications such as hypotension and decreased tissue perfusion.
Acute kidney injury (AKI)
The client's BUN level increased from 10 mg/dL on admission to 20 mg/dL on Day 2, which suggests impaired kidney function. This change may indicate a decrease in glomerular filtration rate due to decreased renal perfusion secondary to fluid loss from diuresis. AKI is a known complication in heart failure patients receiving diuretic therapy, especially if there is inadequate monitoring and adjustment of diuretic doses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Family visits should be limited to 30 minutes per day to minimize their exposure.
A It should be worn consistently by the nurse caring for the client with the radiation implant to monitor their radiation exposure. Giving it to the oncoming nurse at the end of the shift is not appropriate because it does not provide real-time monitoring of radiation exposure for the nurse during their shift.
C. Soiled linens should be kept in the room until the radioactive source is removed to prevent the spread of contamination
D. One should never touch it directly; instead, use long-handled forceps and place it in a lead-lined container for safe disposal.
Correct Answer is C
Explanation
C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.
A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.
B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.
D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.
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