The vital signs for a client with heart failure (HF), who is admitted to the intensive care unit (ICU), are a temperature of 98.6° F (37°C), heart rate 125 beats/minute, respirations 22 breaths/minute, and blood pressure 140/50 mm Hg. The nurse determines the client's central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are elevated. Which intervention should the nurse implement?

A. Initiate an IV bolus of 0.9% normal saline 500 mL. The client already has elevated CVP and PAWP, which indicate fluid overload and poor cardiac function. Giving a fluid bolus would worsen pulmonary congestion, edema, and respiratory distress. Fluid restriction, rather than additional IV fluids, is usually necessary in decompensated heart failure.
B. Titrate IV dopamine at 8 mcg/kg/minute. Dopamine is a vasopressor and inotropic agent that increases blood pressure and cardiac output. However, the client has an elevated blood pressure (140/50 mm Hg) and signs of fluid overload, making dopamine unnecessary. Increasing contractility could further stress the failing heart and worsen congestion.
C. Administer furosemide 40 mg IV push (IVP). Furosemide (a loop diuretic) is the best intervention for fluid overload in heart failure. Elevated CVP and PAWP suggest pulmonary congestion and excess intravascular volume, which furosemide helps relieve by reducing preload and promoting diuresis. This intervention improves breathing, reduces blood pressure, and decreases cardiac workload.
D. Encourage a liberal PO fluid intake. Clients with heart failure often require fluid restriction to prevent worsening edema and pulmonary congestion. Encouraging excessive oral fluid intake would worsen fluid overload and should be avoided.

A. Prepare to give phenytoin IV as prescribed. Phenytoin is used for seizure prophylaxis in clients with moderate to severe head injuries (GCS ≤ 8–10). A GCS score of 14 indicates mild head injury, and prophylactic anticonvulsants may not be necessary unless ordered for specific risk factors.
B. Perform a substernal rub to evoke a response to pain. A substernal rub (painful stimulus) is used to assess response in unconscious or unresponsive clients (GCS ≤ 8). With a GCS of 14, the client is alert or nearly fully conscious, making a painful stimulus unnecessary and inappropriate.
C. Promptly notify the healthcare provider (HCP) of the GCS score. A GCS of 14 is not a critical or emergency finding, as it indicates mild neurological impairment. While the HCP should be updated on significant changes, routine monitoring is sufficient unless deterioration occurs.
D. Continue monitoring the client's GCS score every 2 hours. Frequent neurological assessments are crucial in head injury management to detect worsening conditions like increasing intracranial pressure (ICP) or cerebral edema. Monitoring the GCS every 2 hours ensures timely intervention if the client’s condition changes.