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    Nurs 547 Adult Health Nursing Ii: Cardiovascular Disorders (university Of Maryland) Proctored Exam

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    Question: 1 of 48Nurs 547 Adult Health Nursing II: Cardiovascular Disorders (University Of Maryland) Proctored Exam
    The nurse is rounding on a patient diagnosed with heart failure (HF). The patient is receiving 1 liter of 0.9% sodium chloride at 150 ml/hr with two hours left on the infusion. The nurse observes that the patient has a moist cough, distended neck veins, and dyspnea. What actions should the nurse take? Select all that apply by choosing the three highest priority nursing actions for this patient.

    Select all that apply

    Explanation
    A. Check the patient's temperature: Although assessing temperature is part of a full evaluation, fever is not the priority concern in this scenario. The patient’s moist cough, jugular venous distention, and dyspnea suggest acute fluid overload and worsening heart failure rather than infection. Immediate cardiopulmonary assessment takes precedence. B. Assess the pulse oximetry reading: Dyspnea and signs of volume overload raise concern for pulmonary edema and impaired oxygenation. Measuring oxygen saturation provides rapid, objective data about respiratory compromise and guides urgent interventions such as oxygen therapy. Hypoxemia must be identified promptly to prevent respiratory failure. C. Auscultate the lungs: Lung auscultation is essential to assess for crackles, which indicate fluid accumulation in the alveoli due to left-sided heart failure. Detecting pulmonary congestion supports clinical suspicion of fluid overload and helps determine severity, guiding immediate treatment decisions. D. Contact the provider: The patient is exhibiting signs of acute decompensated heart failure while receiving IV fluids. Prompt provider notification is necessary to obtain orders to adjust or discontinue fluids and initiate diuretic therapy or other interventions to prevent worsening pulmonary edema. E. Change the fluids to 0.45% sodium chloride: The nurse should not independently change the IV solution without a provider order. Additionally, switching to hypotonic fluids does not address the underlying issue of volume overload and could further complicate the patient’s condition. F. Administer furosemide as ordered: Although loop diuretics are commonly used in fluid overload, administration depends on an existing order. Since the question prioritizes immediate assessment and escalation, verifying oxygenation and lung status and notifying the provider are the top initial actions unless a standing order is already in place.
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