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 C

Explanation

A. The client has circumoral cyanosis: Circumoral cyanosis, or bluish discoloration around the mouth, is a sign of hypoxia but may not be present in all cases of hypoxemia. Pulse oximetry provides a more objective measurement.

B. The client's heart rate is 86 bpm: Heart rate may be within normal limits even in the presence of hypoxemia, as compensatory mechanisms may not be fully activated.

C. The client has a pulse ox of 90% on room air: A pulse oximetry reading of 90% indicates hypoxemia (oxygen saturation below normal levels), which is a significant finding, especially in a client with COPD who may already have compromised respiratory function.

D. The client is lethargic: Lethargy may occur with severe hypoxemia, but it is a late sign and may not always be present. Monitoring oxygen saturation is more reliable for early detection of hypoxemia.

A. Isolation gown B. Contact isolation C. Standard precautions D. Respiratory isolation

Correct Answer is C

Explanation

A. Isolation gown: Isolation gowns are used as part of contact precautions or airborne precautions for specific infectious diseases that require additional transmission-based precautions beyond standard precautions. However, standard precautions are generally sufficient for caring for clients with HIV receiving antiretroviral therapy.

B. Contact isolation: Contact isolation is used for patients with known or suspected infections that can be transmitted by direct or indirect contact with the patient or their environment. HIV does not require contact isolation unless there are additional infections or conditions present that warrant contact precautions.
C. Standard precautions: Standard precautions are the basic infection prevention practices that apply to all patient care, regardless of the suspected or confirmed infection status of the patient. This includes practices such as hand hygiene, the use of personal protective equipment (e.g., gloves, gown, mask, eye protection) when indicated, and safe injection practices. Standard precautions should be used for all patients, including those with HIV, to prevent the transmission of infectious agents.
D. Respiratory isolation: Respiratory isolation is used for patients with known or suspected respiratory infections that are transmitted through respiratory droplets. HIV is not transmitted through respiratory droplets and does not require respiratory isolation.

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Naxlex Comprehensive Predictor Exams

A nurse suspects impending respiratory failure in a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse should recognize that which assessment finding supports the presence of hypoxemia?

Correct Answer is C

Explanation

A nurse is providing direction to a nursing assistant who will be caring for a client with human immunodeficiency virus (HIV) and receiving azidothymidine (AZT) antiretroviral therapy. The nurse should instruct the nursing assistant to implement which of the following actions?

Correct Answer is C

Explanation

A nurse is providing discharge instructions to a client who is severely immunocompromised by HIV. Which of the following should the nurse include in the discharge instructions? (Select all that apply.)

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A nurse is caring for a client diagnosed with congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

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A nurse is reviewing a client's arterial blood gas (ABG) results. Which of the following ABG results should the nurse anticipate when caring for a client with acidosis?