Complex Care Flashcards

A heart failure client being discharged home states: 'I can add extra salt to my food to maintain energy levels.' What does this indicate?

Answer: Need for further teaching: extra salt is contraindicated in heart failure

Adding extra salt is contraindicated in heart failure as sodium causes fluid retention worsening cardiac workload and edema.

A client with COPD has ABG: pH 7.32, PaCO2 58 mmHg, HCO3 28 mEq/L. How should this be interpreted?

Answer: Respiratory acidosis with metabolic compensation

pH 7.32 (acidosis) + elevated PaCO2 (respiratory cause) + elevated HCO3 (renal compensation) = respiratory acidosis with metabolic compensation.

A client with suspected DVT in the right leg requires which correction to the nursing care plan?

Answer: Massaging the right calf to relieve discomfort

Massaging a limb with suspected DVT can dislodge the clot, causing potentially fatal pulmonary embolism.

A catheterized client develops fever 38.9 degrees Celsius, chills, and flank pain. What is the priority action?

Answer: Notify the physician immediately and prepare to obtain urine culture

Fever, chills, and flank pain suggest CAUTI or ascending pyelonephritis requiring immediate medical evaluation and culture.

Which alcohol withdrawal assessment finding requires immediate intervention?

Answer: Tonic-clonic seizures and unresponsiveness

Seizures and loss of consciousness indicate severe withdrawal (delirium tremens) requiring emergency intervention.

TPN runs out and a replacement bag is not immediately available. What should the practical nurse do?

Answer: Hang D10W at the same rate until TPN is available

D10W at the same rate maintains glucose supply and prevents rebound hypoglycemia when TPN is interrupted.