Scenario Identify the Top 3 client areas for the nurse to assess….

Question Scenario Identify the Top 3 client areas for the nurse to assess…. ScenarioIdentify the Top 3 client areas for the nurse to assess.An 89-year-old female client is admitted to a telemetry unit with a diagnosis of heart failure exacerbation.  She reports a medical history of osteoarthritis, chronic renal insufficiency, and coronary artery disease including a myocardial infarction and coronary artery bypass surgery 22 years ago.  She is alert and her daughter is at her bedside.  The nurse’s initial client assessment findings include:Oriented to person only, follows simple commandsClear speechSinus tachycardiaRespirations of 26 breaths/minOxygen saturation of 90% on room airBreathing labored with use of accessory musclesProductive cough with pink frothy sputumCrepitus in bilateral knee jointsEnlarged body nodes on handsHemoglobin = 12.4 g/dLHematocrit = 39%White blood cell count = 12,ooo mm3                Next GEN NCLEX: What matters most?  Noticing, Tanner’s Clinical Judgement model Indicate which nursing action listed on the far left column is appropriate for each potential heart failure complication.  Note that not all actions will be used, but there is only one appropriate action for each complication and they can be used only once. Nursing ActionPotential Heart Failure ComplicationAppropriate Nursing Action for each potential heart failure complication Reduce sodium intake to 1g daily.Acute pulmonary edema Administer oxygen therapyFatigue Weight the client each morning on the same scaleHypokalemia Administer furosemide 20 mg IV push.Cardiac dysrhythmia Encourage the client to drink at least 3L of fluid dailyHypoxemia Teach the client pursed-lip breathing techniques.  Administer potassium supplements  Monitor electrocardiogram, oxygen saturation, and serum electrolyte levels.  Reposition every 2 hours while in bed.  Consult a cardiac rehabilitation specialist.   Example: Complication Example: Appropriate actions for complication: #3  Complete a Medication template for each of the following medications: (1) Potassium PO, (2) Furosemide IV push Case Study ProgressThe 80-year-old client will be discharged today and will move in with her daughter until she feels well enough to go home alone.  Which of the following discharge instructions will the nurse provide the client and her daughter? Select all that apply”Weight yourself each day at the same time on the same scale to monitor for fluid retention”Contact your primary health care provider if you experience cold symptoms lasting more than 3 days.”Exertion can cause another episode of heart failure, so help your mother by assisting her with daily activities.”Notify your primary health care provider if you experience shortness of breath or chest pain while resting.””Do not use table salt, avoid salty foods, and read labels on all food items to ensure your diet is low in sodium.””Do not take metoprolol if your heart rate is less than 60 beats per minute.””Heart failure is a chronic condition, so you don’t need to be alarmed when you experience heart palpitations.” Case Study ProgressThe client was discharged 2 weeks ago and is with her daughter for her follow up primary health care provider visit.  For each assessment finding, use an X to indicate whether the interventions are Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes). Assessment findingEffectiveIneffectiveUnrelatedStates that she has had no shortness of breath since hospital discharge   Has 2+ pitting edema in both ankles and feet   Blood pressure of 134.76 mm Hg   Has had no chest pain since hospital discharge   Reports feeling like she has more energy now when compared with before her hospital stay   Has new onset fungal skin infection      Health Science Science Nursing NUR 1015 Share QuestionEmailCopy link Comments (0)