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The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?

Internal bleeding.

Right-sided heart failure.

Left ventricular dysfunction.

Cardiac tamponade.

Answer and Explanation

The Correct Answer is B

A. Internal bleeding typically presents with signs of hypovolemia, such as decreased blood pressure and increased heart rate, rather than pitting edema and jugular venous distention.

B. Right-sided heart failure is characterized by fluid overload, leading to symptoms like pitting edema in the extremities and jugular venous distention, which align with the findings observed in this client.

C. Left ventricular dysfunction primarily results in pulmonary congestion and respiratory distress rather than peripheral edema and jugular venous distention.

D. Cardiac tamponade may present with jugular venous distention, but it usually also involves hypotension and muffled heart sounds, which are not described in this scenario.

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A. Administer aspirin to prevent further clot formation and platelet clumping. B. Maintain elevated positioning of the dependent joints on the affected side. C. Verify prescribed laboratory tests include prothrombin time and platelet count. D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Correct Answer is D

Explanation

A. Administering aspirin is not appropriate at this time, as it may delay treatment for a stroke if that is the underlying cause.

B. Maintaining elevated positioning of the dependent joints is not a priority in this acute situation and does not address the immediate needs of the client showing signs of possible stroke.

C. Verifying laboratory tests like prothrombin time and platelet count is important but is not an immediate intervention that addresses the acute condition.

D. Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is crucial because the client presents with signs of a potential stroke. Rapid identification and treatment are essential to improving outcomes in acute ischemic stroke cases.

A. Limit oral fluid intake to 500 mL/day. B. Restrict protein intake by limiting meats and other high protein foods. C. Increase intake of potassium-rich foods, such as bananas or cantaloupe. D. Increase intake of high-fiber foods, such as bran cereal.

Correct Answer is B

Explanation

A. Limiting oral fluid intake may be necessary in some cases of glomerulonephritis, especially if the client is experiencing edema or hypertension, but this is not a universal recommendation and should be assessed individually.

B. Restricting protein intake is important for clients with glomerulonephritis to reduce the workload on the kidneys and prevent further damage. This is a critical dietary adjustment that nurses should emphasize.

C. Increasing potassium-rich foods can be contraindicated in clients with glomerulonephritis, especially if renal function is compromised, as it can lead to hyperkalemia.

D. While high-fiber foods can be beneficial for overall health, they do not directly address the specific dietary needs of a client with glomerulonephritis in terms of protein and electrolyte balance.

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Correct Answer is D

Explanation

Correct Answer is B

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Correct Answer is D

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The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?

Correct Answer is B

Explanation

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