Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

Encourage fluid intake

Administer prescribed diuretic as ordered.

Monitor daily weight and fluid intake/output.

Educate the patient about low-sodium dietary choices.

Answer and Explanation

Correct Answer : B,C,D

Choice A reason: Encouraging fluid intake worsens heart failure by increasing preload and congestion. Restriction (e.g., 2L/day) is standard to prevent overload, as excess volume exacerbates dyspnea and edema in compromised hearts.

Choice B reason: Administering diuretics like furosemide reduces fluid overload, easing heart failure symptoms. It lowers pulmonary pressure and edema by enhancing excretion, a critical action to stabilize patients and improve breathing.

Choice C reason: Monitoring weight and fluid balance tracks retention in heart failure; a 2-3 lb gain signals worsening. It guides therapy adjustments, ensuring effective management of volume status and preventing decompensation.

Choice D reason: Educating on low-sodium diets (<2g/day) prevents fluid retention in heart failure. Sodium draws water into vessels, worsening congestion; this empowers patients to control symptoms and supports long-term stability.

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Correct Answer is C

Explanation

Choice A reason: Cyanosis requires deoxygenated hemoglobin, not typical in anemia unless hypoxia coexists. Hypertension isn’t linked; anemia often lowers pressure from reduced viscosity, making this pair unlikely in severe cases.

Choice B reason: Pulmonary edema and fibrosis stem from heart or lung disease, not anemia directly. Low hemoglobin reduces oxygen delivery, but these reflect fluid or scarring, not primary anemic findings.

Choice C reason: Dyspnea and tachycardia occur in severe anemia as low hemoglobin limits oxygen transport. The heart compensates with faster beats, and lungs work harder, matching physiologic response to tissue hypoxia.

Choice D reason: Dysrhythmias may occur late in anemia from hypoxia, but wheezing suggests airway issues, not anemia. These aren’t primary findings; respiratory and cardiac strain manifest differently in this condition.

A. Metabolic alkalosis with hypoxemia B. Respiratory alkalosis with hypoxemia C. Metabolic acidosis with hypoxemia D. Respiratory acidosis with hypoxemia

Correct Answer is B

Explanation

Choice A reason: Metabolic alkalosis shows pH >7.45 with HCO3- >26 mEq/L from base excess. Here, pH is 7.48, but HCO3- is normal at 24 mEq/L, ruling out metabolic cause. PaO2 of 55 mmHg indicates hypoxemia, but the primary issue isn’t metabolic.

Choice B reason: Respiratory alkalosis occurs with pH >7.45 and PaCO2 <35 mmHg from hyperventilation. Here, pH is 7.48, PaCO2 is 28 mmHg, and HCO3- is normal, confirming respiratory etiology. PaO2 of 55 mmHg shows hypoxemia, matching this acute ventilatory pattern.

Choice C reason: Metabolic acidosis has pH <7.35 and HCO3- <22 mEq/L from acid gain. Here, pH is 7.48 and HCO3- is 24 mEq/L, contradicting acidosis. PaO2 of 55 mmHg indicates hypoxemia, but the acid-base status is alkalotic, not acidic.

Choice D reason: Respiratory acidosis features pH <7.35 and PaCO2 >45 mmHg from CO2 retention. Here, pH is 7.48 and PaCO2 is 28 mmHg, showing CO2 loss, not retention. Hypoxemia (PaO2 55 mmHg) is present, but the pattern is alkalotic.

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Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

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Naxlex Comprehensive Predictor Exams

In a severely anemic patient, which assessment findings would the nurse expect to find?

Correct Answer is C

Explanation

Interpret the ABG results: pH: 7.48, PaCO2: 28 mmHg, PaO2: 55 mmHg, HCO3-: 24 mEq/L, SaO2: 87%

Correct Answer is B

Explanation

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