{"id":136913,"date":"2024-09-11T13:07:16","date_gmt":"2024-09-11T13:07:16","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=136913"},"modified":"2024-09-11T13:07:19","modified_gmt":"2024-09-11T13:07:19","slug":"a-nurse-is-caring-for-a-client-who-has-heart-failure","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/11\/a-nurse-is-caring-for-a-client-who-has-heart-failure\/","title":{"rendered":"A nurse is caring for a client who has heart failure"},"content":{"rendered":"\n<p>A nurse is caring for a client who has heart failure.<\/p>\n\n\n\n<p>Nurses&#8217; Notes.<\/p>\n\n\n\n<p>Day 1: Vital Signs.<\/p>\n\n\n\n<p>Bilateral breath sounds clear and present throughout.<\/p>\n\n\n\n<p>Weight 80 kg (176 lb). Urine output 480 mL\/8 hr. Day 4: Breath sounds scattered, crackles heard bilaterally.<\/p>\n\n\n\n<p>Apical heart rate rapid and irregular.<\/p>\n\n\n\n<p>Audible S3 gallop.<\/p>\n\n\n\n<p>Weight 82.1 kg (181 lb). Urine output 320 mL\/8 hr. Vital Signs.<\/p>\n\n\n\n<p>Day 1: Temperature 37.6\u00b0 C (99.7\u00b0 F). Blood pressure 108\/50 mm Hg. Pulse 98\/min.<\/p>\n\n\n\n<p>Respiratory rate 20\/min.<\/p>\n\n\n\n<p>Pulse oximetry 95% on room air.<\/p>\n\n\n\n<p>Day 4: Temperature 36.8\u00b0 C (98.2\u00b0 F). Blood pressure 138\/80 mm Hg. Pulse 112\/min.<\/p>\n\n\n\n<p>Respiratory rate 28\/min.<\/p>\n\n\n\n<p>Pulse oximetry 88% on room air.<\/p>\n\n\n\n<p>A nurse is reviewing the assessment findings for the client on day 4. Which of the following findings requires further action? (Select all that apply.).<\/p>\n\n\n\n<p>A.<br>Temperature.<\/p>\n\n\n\n<p>B.<br>Oxygen saturation.<\/p>\n\n\n\n<p>C.<br>Blood pressure.<\/p>\n\n\n\n<p>D.<br>Weight.<\/p>\n\n\n\n<p>E.<br>Urine output.<\/p>\n\n\n\n<p>F.<br>Breath sounds.<\/p>\n\n\n\n<p><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-ast-global-color-6-color\"><strong>The correct answer and Explanation is :<\/strong><\/mark><\/p>\n\n\n\n<p>For the client with heart failure, the findings that require further action are:<\/p>\n\n\n\n<p><strong>B. Oxygen saturation.<\/strong><\/p>\n\n\n\n<p><strong>C. Blood pressure.<\/strong><\/p>\n\n\n\n<p><strong>D. Weight.<\/strong><\/p>\n\n\n\n<p><strong>F. Breath sounds.<\/strong><\/p>\n\n\n\n<p><strong>Explanation:<\/strong><\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>Oxygen Saturation (B):<\/strong> On Day 4, the pulse oximetry reading is 88% on room air, which is below the normal range of 95-100%. This indicates that the client is experiencing hypoxemia, which could be due to worsening heart failure or pulmonary congestion. Immediate action is needed to assess and address the cause of the decreased oxygen saturation. This might include supplemental oxygen, further respiratory assessment, or adjustments to heart failure management.<\/li>\n\n\n\n<li><strong>Blood Pressure (C):<\/strong> The blood pressure has increased from 108\/50 mm Hg on Day 1 to 138\/80 mm Hg on Day 4. This elevation can indicate worsening heart failure or a possible hypertensive crisis, which requires prompt evaluation and possible adjustment of antihypertensive medications or heart failure treatment to manage the blood pressure effectively.<\/li>\n\n\n\n<li><strong>Weight (D):<\/strong> The client&#8217;s weight has increased from 80 kg (176 lb) to 82.1 kg (181 lb). An increase in weight, particularly in a short period, suggests fluid retention, which is a common sign of worsening heart failure. This could indicate inadequate fluid management or increased congestion and requires further assessment and possible intervention to manage fluid balance.<\/li>\n\n\n\n<li><strong>Breath Sounds (F):<\/strong> The change in breath sounds from clear to scattered with crackles bilaterally on Day 4 suggests fluid accumulation in the lungs, indicative of worsening heart failure. Crackles are often associated with pulmonary edema, which requires prompt management to prevent respiratory distress and further complications.<\/li>\n<\/ol>\n\n\n\n<p><strong>Temperature (A)<\/strong> and <strong>Urine Output (E)<\/strong>, while important, do not show immediate concerning changes in this context compared to the other findings. Temperature is within normal limits, and although urine output has decreased, it may be less urgent if other signs are more critical. However, monitoring these parameters is still important for overall assessment and management.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A nurse is caring for a client who has heart failure. Nurses&#8217; Notes. Day 1: Vital Signs. Bilateral breath sounds clear and present throughout. Weight 80 kg (176 lb). Urine output 480 mL\/8 hr. Day 4: Breath sounds scattered, crackles heard bilaterally. Apical heart rate rapid and irregular. Audible S3 gallop. Weight 82.1 kg (181 [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-136913","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/136913","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=136913"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/136913\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=136913"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=136913"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=136913"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}