The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?
Lung sounds
Facial swelling
Level of anxiety
Intake and output
The Correct Answer is A
In a patient with acute decompensated heart failure (ADHF), the priority nursing assessment is to auscultate lung sounds. ADHF is characterized by the sudden worsening of heart failure symptoms, which may include pulmonary congestion and fluid accumulation in the lungs. Assessing lung sounds helps to identify signs of pulmonary edema, which is a serious complication of ADHF.
The nurse should listen for crackles or rales, which are abnormal lung sounds caused by the presence of fluid in the alveoli. These findings suggest that the patient is experiencing fluid overload and inadequate gas exchange in the lungs. Prompt recognition of pulmonary edema allows for early intervention, such as administering diuretics or other medications, to relieve fluid overload and improve respiratory function.
While the other options (B) Facial swelling, (C) Level of anxiety, and (D) Intake and output, are important assessments in a patient with heart failure, they are not the priority in a patient with manifestations of acute decompensated heart failure. The priority is to assess for signs of respiratory
distress and pulmonary congestion, as these can quickly lead to respiratory failure and life threatening complications.
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Related Questions
Correct Answer is A
Explanation
In a patient with acute decompensated heart failure (ADHF), the priority nursing assessment is to auscultate lung sounds. ADHF is characterized by the sudden worsening of heart failure symptoms, which may include pulmonary congestion and fluid accumulation in the lungs. Assessing lung sounds helps to identify signs of pulmonary edema, which is a serious complication of ADHF.
The nurse should listen for crackles or rales, which are abnormal lung sounds caused by the presence of fluid in the alveoli. These findings suggest that the patient is experiencing fluid overload and inadequate gas exchange in the lungs. Prompt recognition of pulmonary edema allows for early intervention, such as administering diuretics or other medications, to relieve fluid overload and improve respiratory function.
While the other options (B) Facial swelling, (C) Level of anxiety, and (D) Intake and output, are important assessments in a patient with heart failure, they are not the priority in a patient with manifestations of acute decompensated heart failure. The priority is to assess for signs of respiratory
distress and pulmonary congestion, as these can quickly lead to respiratory failure and life threatening complications.
Correct Answer is D
Explanation
A patient with chronic kidney disease is at risk for hyperphosphatemia. In chronic kidney disease, the kidneys' ability to excrete phosphate is impaired, leading to elevated levels of phosphate in the blood. This can further lead to calcium-phosphate imbalances, bone problems, and other complications associated with kidney disease. Managing phosphate levels is an essential aspect of the treatment plan for patients with chronic kidney disease.
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