Exhibits

A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider's office. The nurse reviews the client's medical records to prepare the client's plan of care.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing: Heart failure.

The client presents with signs and symptoms consistent with heart failure, including cardiomegaly, bibasilar pleural congestion on chest x-ray, elevated BNP level, and vital signs indicating hypertension (BP 146/98 mm Hg), tachycardia (pulse rate 106/min), and tachypnea (respirations 24/min). Additionally, the client is prescribed medications commonly used to manage heart failure, such as digoxin and carvedilol, and is receiving a diuretic (furosemide) to address fluid overload associated with heart failure.
Action to Take:

Elevate the head of the bed: Elevating the head of the bed helps reduce venous return to the heart, decreasing preload and potentially alleviating symptoms of heart failure, such as dyspnea and orthopnea. It can also help prevent aspiration in clients with compromised cardiac function. Encourage intake of a low-sodium diet: A low-sodium diet is essential in managing heart failure as it helps reduce fluid retention and edema by decreasing fluid volume overload. Sodium restriction helps minimize fluid accumulation, which is crucial in preventing exacerbations of heart failure.
Parameter to Monitor:

Urinary output: Monitoring urinary output is important in assessing fluid balance and response to diuretic therapy in clients with heart failure. Decreased urinary output may indicate worsening heart failure or inadequate response to diuretic therapy, whereas increased output may suggest over-diuresis or improvement in heart failure symptoms.
Blood pressure: Monitoring blood pressure helps assess the effectiveness of treatment in managing heart failure and controlling hypertension, a common comorbidity. Hypertension can exacerbate heart failure, so monitoring blood pressure trends helps guide adjustments in medication therapy to achieve optimal blood pressure control and improve cardiac function.

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Correct Answer is A

Explanation

A. Irregular pulsations: Premature ventricular contractions (PVCs) are abnormal heartbeats originating in the ventricles, causing irregularities in the heart rhythm. Auscultating the apical pulse during PVCs may reveal irregular pulsations due to the irregular timing of ventricular contractions.

B. Bounding pulsations: Bounding pulsations are typically associated with conditions such as hypertension or aortic valve regurgitation but are not specifically characteristic of PVCs.

C. Tachycardia: PVCs may occur in the setting of tachycardia, but the presence of PVCs themselves does not necessarily indicate a rapid heart rate. The rhythm may be irregular due to PVCs, but the overall heart rate may not be consistently elevated.

D. Bradycardia: PVCs are not typically associated with bradycardia. Bradycardia refers to a slow heart rate, while PVCs involve premature extra beats originating from the ventricles.

A. Administration of erythropoietin (Epoetin). B. Transfusion of red blood cells (RBCs). C. Weekly monitoring of complete blood count (CBC). D. An order for iron replacement medication.

Correct Answer is A

Explanation

A. Administration of erythropoietin (Epoetin): In chronic renal disease, the kidneys may not produce enough erythropoietin, leading to anemia. Epoetin is a synthetic form of erythropoietin that stimulates red blood cell production and is commonly used to treat anemia in these clients.

B. Transfusion of red blood cells (RBCs): While transfusion of RBCs may be necessary in severe cases of anemia or acute blood loss, it is not the first-line treatment for anemia related to chronic renal disease. Erythropoietin-stimulating agents are preferred to stimulate endogenous RBC production.

C. Weekly monitoring of complete blood count (CBC): Monitoring of CBC is important to assess the response to treatment and adjust therapy as needed but does not represent a specific treatment for anemia in chronic renal disease.

D. An order for iron replacement medication: Iron replacement may be indicated if iron deficiency is contributing to the anemia, but it is not the primary treatment for anemia in chronic renal disease. Erythropoietin-stimulating agents are typically used first to address the underlying cause of anemia.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client with chronic renal disease is experiencing manifestations of anemia. Based on this data, which treatment should the nurse anticipate for this client?

Correct Answer is A

Explanation

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