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 ["A","B","C","D","E","F"]
Explanation
Restlessness can be a sign of inadequate oxygenation to the brain, known as hypoxia. This is particularly concerning in a client with COPD whose oxygen saturation is already low (87% on room air).
These pulmonary findings indicate worsening respiratory distress in a client with COPD. Tachypnea, productive cough with discolored sputum, and abnormal lung sounds (wheezes and crackles) suggest exacerbation of COPD. The oxygen saturation of 87% on room air is below normal (typically 95% or higher), indicating hypoxemia, which requires immediate assessment and intervention to prevent further respiratory compromise.
The elevated heart rate (110/min) may indicate increased workload on the heart due to respiratory distress and hypoxemia.
Correct Answer is B
Explanation
B. Asking the client if they feel like they have food stuck at the base of their throat directly assesses for the hallmark symptom of dysphagia associated with achalasia. This symptom is crucial in diagnosing and monitoring the condition.
A This question assesses for symptoms of esophageal reflux (heartburn), which may not directly relate to the mechanical difficulty of swallowing associated with oral achalasia.
C. This question focuses on sensations of fullness in the neck, which may not specifically relate to swallowing difficulty associated with achalasia.
D. This question assesses for pain during swallowing, which can occur in conditions affecting the throat or esophagus, but it does not specifically address the unique symptom of feeling like food is stuck, which is more typical in achalasia.
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