A nurse is caring for a client who is postpartum and requests information about contraception. Which of the following instructions should the nurse include?

Rationale:

A. A client who has dementia and is incontinent of urine: This client has multiple contributing factors, cognitive impairment limits repositioning and self-care, while urinary incontinence increases skin moisture and maceration, promoting skin breakdown and pressure injury formation.

B. A client who is 2 days postoperative following orthopedic surgery: Although this client may have limited mobility, they are typically on a monitored recovery path with interventions like repositioning, early ambulation, and pain management, reducing their overall risk.

C. A client who has a T-tube following an open cholecystectomy: This client is generally alert, mobile with assistance, and able to communicate needs, which lowers their risk of pressure injury compared to more dependent individuals.

D. A client who has had a recent myocardial infarction: This client may be monitored in bed rest initially, but cardiovascular stability and mobility often improve quickly with treatment, making their pressure injury risk moderate rather than the highest among the group.

Rationale for Correct Choices

• Heart failure: The client’s symptoms bilateral crackles, +3 lower extremity edema, cool limbs with weak pulses, an S3 heart sound, and elevated BNP are classic signs of decompensated heart failure with volume overload and poor perfusion.
• Educate the client about sodium restriction: Sodium contributes to fluid retention and increased cardiac workload. Dietary sodium restriction is crucial in preventing fluid overload, thus reducing exacerbations of heart failure symptoms such as edema and dyspnea.
• Obtain a prescription for a diuretic: Diuretics like furosemide relieve volume overload by promoting fluid excretion. They help decrease pulmonary congestion, improve oxygenation, and reduce peripheral edema in heart failure patients.
• Daily weight: Monitoring weight helps detect subtle changes in fluid balance. A sudden weight gain of 2–3 pounds in 24 hours may signal worsening heart failure and the need for diuretic adjustment.
• Blood pressure: Blood pressure monitoring provides insight into cardiac output and guides medication titration. Both hypertension and hypotension can worsen outcomes in clients with heart failure.

Rationale for Incorrect Choices

• Endocarditis: This condition presents with fever, new or changing murmurs, petechiae, or positive blood cultures. The absence of infection signs and the presence of systemic fluid overload point away from endocarditis.
• Aortic stenosis: Typical signs include exertional dyspnea, syncope, chest pain, and a harsh systolic murmur not crackles, edema, or elevated BNP. This client’s profile better matches heart failure.
• Mitral stenosis: This condition may cause pulmonary congestion but often presents with a diastolic murmur and atrial fibrillation, which are not described here.
• Administer antibiotics as prescribed: Without clinical or laboratory signs of infection (fever, leukocytosis, or positive cultures), antibiotics are not appropriate for heart failure.
• Prepare the client for cardioversion: Cardioversion is used for arrhythmias like atrial fibrillation with rapid ventricular response. The client has a normal apical pulse and no dysrhythmia signs.
• Educate the client about valve replacement: Valve surgery is not indicated unless diagnostic findings confirm severe valvular disease. No murmur or echo data is provided here.
• Skin lesions: These are associated with endocarditis, not heart failure. Findings like Janeway lesions or Osler nodes are not reported in this case.
• Blood cultures: Indicated when bacteremia or endocarditis is suspected. Heart failure without infection signs does not warrant blood cultures.
• Fever: The client is afebrile, making infection less likely. Fever is not a feature of uncomplicated heart failure and does not need monitoring here.