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.
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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Correct Answer is A
Explanation
A. Acute pain is the most immediate and pressing problem for the client, given the reported severe flank pain. Managing pain effectively is a primary concern in nursing care, particularly for clients with renal calculi.
B. While impaired renal function is a concern with renal calculi, the acute pain takes precedence as it requires immediate intervention to enhance the client's comfort and promote better overall health.
C. The risk for aspiration is a potential issue due to nausea and vomiting; however, addressing the pain is more urgent in this scenario.
D. Nutritional deficit related to nausea is also a valid concern but is secondary to the acute pain management. The client’s immediate comfort and pain relief should be prioritized to facilitate recovery and improve overall well-being.
Correct Answer is B
Explanation
A. Avoiding frequent eye pressure measurements is not advisable; monitoring eye pressure is crucial in managing glaucoma.
B. Maintaining the prescribed eye drop regimen is the most important instruction because consistent use of these medications is critical to managing intraocular pressure and preventing vision loss associated with glaucoma.
C. While wearing prescription glasses can assist with vision, it does not address the underlying condition of glaucoma.
D. Eating a diet high in carotene is beneficial for overall eye health but does not directly impact the management of glaucoma. Regular use of prescribed eye drops is essential to prevent further damage to the optic nerve and potential blindness.