The nurse is caring for a client who has heart failure with an EF of 40%. The client has a BP of 170/67 with an HR of 60. He currently is in normal sinus rhythm and has an amber urine output of 45ml in the last 3 hours. Which medication would the nurse expect to give first?
Isosorbide PO
Nitroglycerin Drip
Dopamine drip
Normal Saline Bolus
The Correct Answer is D
D Normal saline bolus administration is indicated for hypovolemia or inadequate intravascular volume, which can lead to decreased cardiac output and hypotension. In this scenario, the client has an amber urine output of 45ml in the last 3 hours, indicating decreased urine output and potential hypovolemia. The elevated blood pressure (170/67 mmHg) suggests possible volume overload or fluid retention, but the decreased urine output raises concerns for inadequate intravascular volume. Therefore, administering a normal saline bolus may be the first priority to optimize intravascular volume and improve cardiac output.
A Isosorbide mononitrate is a vasodilator commonly used in the treatment of heart failure and angina. It helps reduce preload and afterload, thereby decreasing the workload on the heart. However, in this scenario, the client's blood pressure is elevated (170/67 mmHg), and there is no indication of acute decompensation or pulmonary congestion. Therefore, isosorbide PO may not be the first priority medication at this time.
B Nitroglycerin is a potent vasodilator commonly used to manage acute heart failure exacerbations and acute coronary syndromes. It helps reduce preload and afterload, improving cardiac output and relieving symptoms of heart failure. In this scenario, the client's blood pressure is elevated, but the heart rate is normal, and there are no signs of acute decompensation. Therefore, initiating a nitroglycerin drip may not be the first priority unless the client develops symptoms of acute decompensation or pulmonary congestion.
C Dopamine is a vasopressor medication that can be used to increase blood pressure and cardiac output in patients with hypotension or shock. However, in this scenario, the client's blood pressure is elevated (170/67 mmHg), and there is no evidence of hypotension. Therefore, initiating a dopamine drip may not be appropriate at this time and could potentially exacerbate hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Cheyne-Stokes respirations involve a cyclical pattern of breathing characterized by gradual increase and decrease in the depth and rate of respirations, with periods of hyperventilation alternating with periods of apnea. It is commonly seen in patients with neurological disorders, heart failure, or drug overdose.
A. Apneustic respirations are characterized by prolonged inspiratory gasps followed by a brief pause and insufficient expiration. This pattern is often associated with damage to the pons in the brainstem.
C. Stridor is a high-pitched, noisy respiratory sound caused by turbulent airflow through partially obstructed airways. It is typically heard during inspiration and is often associated with upper airway obstruction, such as in cases of croup or epiglottitis.
D. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in patients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.
Correct Answer is B
Explanation
B. Assessing the client's vital signs, including blood pressure and pulse, provides critical information about the client's hemodynamic status and response to the new rhythm. Atrial fibrillation can lead to rapid, irregular heart rates and hemodynamic instability, so obtaining vital signs promptly helps the nurse determine the severity of the situation and whether immediate intervention is needed.
A. This action is not the priority when the nurse observes a new onset of atrial fibrillation. While beta- blockers such as metoprolol may be part of the client's long-term management for heart failure and atrial fibrillation, initiating medication administration without further assessment could delay appropriate intervention for the acute change in rhythm.
C. While it is important to communicate changes in the client's condition to the healthcare provider, this action should occur after the nurse has assessed the client's vital signs and determined the urgency of the situation. If the client is stable and responsive to initial interventions, the nurse can then contact the healthcare provider to discuss the new onset of atrial fibrillation and collaborate on further management.
D. Documenting the changes in the client's rhythm is important for continuity of care and communication among healthcare team members. However, obtaining a rhythm strip should not be the first action when a new onset of atrial fibrillation is observed. Assessing the client's vital signs and initiating appropriate interventions to address any hemodynamic instability take precedence.
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