A nurse is caring for a client who is experiencing an exacerbation of heart failure.
Findings upon admission:
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings related to the diagnosis of heart failure?
Shortness of breath with exertion
Lung sounds clear
WBC count 11,800/mm3
Temperature 38.5° C (101.3° F)
Weight 113 kg (249 lb)
Creatinine 1.8
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"C"}}
Indication of potential improvement:
• Shortness of breath with exertion
• Lung sounds clear
Indication of potential worsening condition:
• WBC count 11,800/mm³
• Temperature 38.5°C (101.3°F)
• Weight 113 kg (249 lb)
• Creatinine 1.8 mg/dL
Rationale:
• Shortness of breath with exertion: Previously, the client had dyspnea at rest. Improvement to exertional dyspnea suggests better fluid balance and cardiac function.
• Lung sounds clear: The initial presence of crackles indicated pulmonary congestion. Clear lung sounds suggest reduced fluid overload, reflecting improved cardiac function.
• WBC count 11,800/mm³: An increasing WBC count suggests a possible infection, which can worsen heart failure by increasing metabolic demands and fluid retention.
• Temperature 38.5°C (101.3°F): Fever indicates a possible infection, such as a UTI, which the client has a history of. Infections can exacerbate heart failure by triggering systemic inflammation and fluid shifts.
• Weight 113 kg (249 lb): Weight gain in heart failure is often due to fluid retention, indicating worsening congestion.
• Creatinine 1.8 mg/dL: A rising creatinine level suggests worsening kidney function, which may result from reduced perfusion due to heart failure or excessive diuresis from furosemide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Desmopressin acetate: This synthetic form of antidiuretic hormone (ADH) reduces excessive urine output by increasing water reabsorption in the kidneys. It helps restore fluid balance and prevent dehydration in diabetes insipidus. Without treatment, continued polyuria can lead to severe dehydration and electrolyte imbalances.
B. Spironolactone: This potassium-sparing diuretic promotes sodium and water excretion by blocking aldosterone receptors. It is used to treat conditions like heart failure and hyperaldosteronism but would worsen polyuria and dehydration in diabetes insipidus.
C. Furosemide: This loop diuretic inhibits sodium and chloride reabsorption in the kidneys, leading to increased urine output. Administering it to a client with diabetes insipidus would further aggravate excessive fluid loss and the risk of dehydration.
D. Dopamine: This vasopressor is used to improve cardiac output and blood pressure in conditions like shock. It does not affect ADH levels or urine concentration and would not help manage the excessive diuresis seen in diabetes insipidus.
Correct Answer is D
Explanation
A. "Use the incentive spirometer every 4 hours.": Incentive spirometry is typically recommended every 1 to 2 hours while awake to promote lung expansion and prevent atelectasis. Less frequent use may not provide adequate lung re-expansion, especially after surgery.
B. "Avoid coughing during and after the session.": Coughing is encouraged after using an incentive spirometer to help clear secretions and prevent respiratory complications such as pneumonia. Suppressing a cough can lead to mucus retention and increased risk of infection.
C. "Remove the mouthpiece and exhale quickly.": The client should exhale normally before using the spirometer, then inhale slowly through the mouthpiece to maximize lung expansion. Rapid exhalation does not promote adequate alveolar inflation.
D. "Place the mouthpiece in your mouth and inhale slowly.": Slow, deep inhalation through the spirometer allows for maximum lung expansion, reducing the risk of atelectasis. The client should maintain a steady breath to ensure optimal lung inflation and hold it for a few seconds before exhaling.
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