The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

Weigh patient using bed scale and restrict oral fluids.

Obtain pulse oximetry levels and assess the respiratory status.

Elevate lower extremity on two pillows while patient is in bed.

Obtain a Physical Therapy consultation to evaluate activity tolerance.

Answer and Explanation

The Correct Answer is B

Choice A reason: Weighing the patient using a bed scale and restricting oral fluids are important interventions for managing fluid balance in heart failure, but they are not the immediate priority. Assessing the respiratory status takes precedence to ensure the patient is not in respiratory distress.

Choice B reason: Obtaining pulse oximetry levels and assessing the respiratory status are priority actions. Dyspnea on exertion and fatigue indicate potential respiratory compromise, and it is crucial to evaluate oxygenation and respiratory function immediately.

Choice C reason: Elevating the lower extremity on two pillows while the patient is in bed can help reduce edema but is not the immediate priority. Respiratory assessment and stabilization take precedence.

Choice D reason: Obtaining a Physical Therapy consultation to evaluate activity tolerance is beneficial for long-term management but is not an immediate priority in acute care. The focus should be on assessing and stabilizing the patient's respiratory and cardiac status.

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Correct Answer is A

Explanation

Choice A reason: The ABG results of pH 7.21, PaCO2 36, HCO3 14 indicate metabolic acidosis, which is common in patients with end-stage kidney disease (ESKD). In ESKD, the kidneys lose their ability to excrete acid and maintain bicarbonate levels, leading to an accumulation of acid in the blood. This condition results in a low pH (acidic), normal PaCO2 (as the respiratory system attempts to compensate), and low HCO3 (bicarbonate).

Choice B reason: The ABG results of pH 7.50, PaCO2 29, HCO3 22 indicate respiratory alkalosis, which is not typically associated with ESKD. Respiratory alkalosis occurs when there is excessive exhalation of carbon dioxide, leading to a higher pH (alkaline). This condition is more likely to be seen in situations such as hyperventilation, anxiety, or certain lung diseases.

Choice C reason: The ABG results of pH 7.47, PaCO2 45, HCO3 33 indicate metabolic alkalosis, which is not typically associated with ESKD. Metabolic alkalosis occurs when there is an excess of bicarbonate or a loss of acid. This condition can result from factors such as vomiting, diuretic use, or excessive antacid consumption. It is not a common finding in patients with ESKD.

Choice D reason: The ABG results of pH 7.31, PaCO2 48, HCO3 24 indicate respiratory acidosis, which is not typically associated with ESKD. Respiratory acidosis occurs when there is an accumulation of carbon dioxide due to impaired respiratory function. This condition is more likely to be seen in chronic obstructive pulmonary disease (COPD) or other respiratory disorders. It is not a common finding in patients with ESKD.

A. pH 7.26, PaCO2 59, HCO3 30 B. pH 7.46, PaCO2 30, HCO3 24 C. pH 7.48, PaCO2 42, HCO3 29 D. pH 7.31, PaCO2 34, HCO3 18

Correct Answer is C

Explanation

Choice A reason: The lab results pH 7.26, PaCO2 59, HCO3 30 indicate respiratory acidosis with partial compensation. This finding is inconsistent with the expected results for a patient with small bowel obstruction and nasogastric suction, which typically leads to metabolic alkalosis due to loss of gastric acid.

Choice B reason: The lab results pH 7.46, PaCO2 30, HCO3 24 suggest a slightly alkaline state with normal bicarbonate levels, which could indicate respiratory alkalosis with compensation. However, for a patient with a small bowel obstruction and nasogastric suction, this is less likely.

Choice C reason: The lab results pH 7.48, PaCO2 42, HCO3 29 indicate metabolic alkalosis. This is a common finding in patients with small bowel obstruction who have been on nasogastric suction, which removes stomach acids and leads to an increase in bicarbonate levels. The elevated pH and bicarbonate levels are consistent with this condition.

Choice D reason: The lab results pH 7.31, PaCO2 34, HCO3 18 indicate metabolic acidosis. This finding is inconsistent with the expected results for a patient with small bowel obstruction and nasogastric suction, which typically leads to

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The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is C

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