RN Nursing · Heart Failure · Practice question
A nurse is caring for a patient. Select-and-drop to complete diagram: condition____, 2 actions____ and ____, 2 parameters____ and ____.
Scenario overview
● 84-year-old male admitted from provider's office.
● History: Macular degeneration, osteoarthritis.
● Diagnostic results:
o BNP 352 pg/mL (elevated >100) → indicates heart failure.
o Chest x-ray: cardiomegaly, bibasilar pleural congestion.
o Labs: LDL 142 (high), HDL 35 (low).
o Vital signs: BP 146/98, HR 106, RR 24, O2 sat 94% on 2 L/min.
● Medications: Metformin, digoxin, carvedilol, furosemide IV bolus once now.
Answer & explanation
Correct:
The clinical scenario presents an 84-year-old male with a BNP of 352 pg/mL (elevated, indicating heart failure), cardiomegaly, bibasilar pleural congestion on chest X-ray, and vital signs showing elevated BP, tachycardia, tachypnea, and reduced oxygen saturation. These findings collectively point to heart failure as the primary condition. The two priority nursing actions for heart failure are elevating the head of the bed to reduce preload and ease respiratory effort, and encouraging a low-sodium diet to prevent fluid retention and reduce cardiac workload. Both interventions directly address the pathophysiology of fluid overload seen in heart failure. The two parameters to monitor are blood pressure — essential given both the hypertension and the vasoactive medications being used — and urinary output, which reflects renal perfusion and the effectiveness of diuretic therapy (furosemide is prescribed). HbA1c is relevant to diabetes management, not heart failure monitoring in this context. Encouraging iron-rich foods pertains to anemia care, assessing feet for sensation relates to diabetic neuropathy, and teaching signs of hyperglycemia pertains to diabetes education — none of which are the primary concern here. Monitoring troponin and potassium would be secondary considerations rather than the lead parameters in this heart-failure–focused scenario.
Study note
Heart Failure: A Nursing Overview
What heart failure is, how left-sided and right-sided failure differ, and the nursing priority that catches fluid overload earliest.
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