Which assessment finding in a patient admitted with acute ...

[saliriagwu]

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse?
 
  a. Oxygen saturation of 88
  b. Weight gain of 1 kg (2.2 lb)
  c. Heart rate of 106 beats/minute
  d. Urine output of 50 mL over 2 hours

Question 2

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first?
 
  a. A patient who is cool and clammy, with new-onset confusion and restlessness
  b. A patient who has crackles bilaterally in the lung bases and is receiving oxygen.
  c. A patient who had dizziness after receiving the first dose of captopril (Capoten)
  d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

[Jayson]

Answer to Question 1

ANS: A
A decrease in oxygen saturation to less than 92 indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.

Answer to Question 2

ANS: A
The patient who has wet-cold clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.

[saliriagwu]

Gracias!

[JaynaD87]

Excellent