The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

weigh the client to obtain a baseline for comparison

Insert an indwelling catheter

Draw blood for chemistry studies and a CBC

Administer furosemide 40mg PO

Answer and Explanation

The Correct Answer is A

A.   Weighing the client provides an important baseline for monitoring fluid retention and determining the effectiveness of treatments such as diuretics. Rapid changes in weight can indicate worsening heart failure and fluid accumulation.
B.   Inserting an indwelling catheter is not indicated unless there are concerns about urinary retention or output, which are not the priority here.
C.   Drawing blood for chemistry studies and a CBC is important but it does not directly address the immediate concern of fluid retention and worsening heart failure.
D.   Administering furosemide may be necessary depending on the client's condition, but first establishing a baseline weight is important before making further treatment decisions.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Ventricular fibrillation (VF) is characterized by a chaotic, rapid, and irregular electrical activity on the ECG, with no identifiable QRS complexes, P waves, or T waves. The heart quivers ineffectively, leading to no blood flow or cardiac output, which results in rapid loss of consciousness and is life-threatening.

Immediate defibrillation is required to restore a normal rhythm. A high-energy shock is delivered to the heart to reset the electrical activity, potentially allowing the heart's natural pacemaker to regain control and resume normal function.

A. Report the findings and anticipate a medical prescription for amiodarone B. Initiate a rapid response call and increase the monitor's sensitivity C. Start compressions and prepare for defibrillation D. Establish unresponsiveness and check the carotid pulse

Correct Answer is D

Explanation

A. Reporting the findings and anticipating a prescription for amiodarone may be necessary later, but the first step is to assess the patient's immediate condition (unresponsiveness, pulse status, etc.).
B. Although increasing monitor sensitivity and initiating a rapid response call might be helpful, these actions come after assessing the patient’s condition. If the patient is in distress or unresponsive, the nurse needs to check for a pulse and intervene right away.
C. This is a crucial action if the patient is unresponsive and pulseless (cardiac arrest). If the patient is found to be unresponsive and pulseless, starting chest compressions immediately and preparing for defibrillation is the next step. However, the first action is to check for pulse and responsiveness.
Why it's incorrect: Compressions and defibrillation are correct actions if the patient is pulseless, but before taking these steps, the nurse must assess the patient for responsiveness and check the carotid pulse. Starting CPR and preparing defibrillation without verifying the patient's condition could delay appropriate care.
D. Checking responsiveness and pulse is the most immediate and critical action because VT may be asymptomatic or cause deterioration, including cardiac arrest. Once pulse and responsiveness are determined, appropriate interventions (such as defibrillation or CPR) can be initiated quickly.

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The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Complete the following sentences with the list of drop down The nurse assesses the client's rhythm on the monitor. The patient is unresponsive with no pulse. The nurse identifies the rhythm asdropdown. The nurse's priority action isdropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

The nurse observes the following rhythm of a client on the telemetry unit. Which action should be completed first?

Correct Answer is D

Explanation

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