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.
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Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The nurse should first address the client pain level followed by the client's ECG results
Rationale
Pain level: Addressing the client's pain level is crucial because it directly affects their comfort and can be indicative of ongoing myocardial ischemia or infarction. The client initially reported chest pain as 7/10, which is significant. Although it has decreased to 5/10 after nitroglycerin, ongoing assessment of pain is essential to ensure it does not worsen or change in nature.
ECG results: The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes. These findings indicate acute myocardial ischemia or infarction, which is a critical concern. The ECG results guide further diagnosis and treatment decisions, such as determining the need for immediate reperfusion therapy (like thrombolytics or angioplasty).
Correct Answer is B
Explanation
B. Desmopressin is a synthetic analog of vasopressin (antidiuretic hormone) that promotes water reabsorption in the kidneys, reducing urine production. It is used to treat conditions associated with excessive urination, such as diabetes insipidus or nocturnal enuresis. Since the client is experiencing excessive thirst and polyuria (excessive urine output), desmopressin would be appropriate to help reduce urine volume and manage fluid balance.
A Given the client's already high urine output, administering furosemide would further increase urine production, potentially exacerbating fluid loss and dehydration.
C. Epinephrine does not address the underlying issue of excessive thirst and polyuria related to brain injury and would not be used in this context.
D. Nitroprusside is a vasodilator that reduces blood pressure by relaxing smooth muscle in blood vessels. It is used to treat hypertensive emergencies. Nitroprusside is not relevant for addressing excessive thirst and polyuria due to brain injury.
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