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. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.
A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.
C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.
D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning
Correct Answer is D
Explanation
D. After inhaling the medication, holding the breath for about 10 seconds allows the medication to settle in the lungs and be absorbed effectively into the bloodstream. This improves the medication's effectiveness in controlling asthma symptoms.
A Waiting 30 seconds between puffs is not a standard instruction; instead, it is generally advised to wait about one minute between puffs if multiple doses are needed.
B. The whistling sound may indicate that the client is inhaling too quickly or forcefully, which can prevent the medication from reaching the lungs effectively.
C. Cleaning the spacer is also crucial, but it is typically recommended to use warm soapy water rather than cold water, and it should be left to air dry.
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