Author Question: A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take ... (Read 105 times)

scienceeasy · **on:** Jun 25, 2018

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of just blowing up and has peripheral edema and shortness of breath.

Which assessment should the nurse complete first?
a. Skin turgor
b. Heart sounds
c. Mental status
d. Capillary refill

Question 2

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

a. Avoid using friction when cleaning around the CVAD insertion site.
b. Use the push-pause method to flush the CVAD after giving medications.
c. Obtain an order from the health care provider to change CVAD dressing.
d. Position the patient's face toward the CVAD during injection cap changes.

tjayeee · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

Answer to Question 2

ANS: B
The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. The patient should turn away from the CVAD during cap changes.