A client with cardiomyopathy receiving diuretic therapy has a urine output of 200 mL in 8 hours. Which action by the nurse is correct?

Correct Answer: C

Rationale: A urine output of 200 mL in 8 hours is considered low, especially for a client with cardiomyopathy who is receiving diuretic therapy. This could indicate inadequate cardiac output or worsening heart failure. It is crucial for the nurse to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the underlying cause and prevent further complications. Waiting for improvement without taking action could lead to deterioration in the client's condition.

Correct Answer: C

Rationale: The priority outcome for a client with deep vein thrombosis (DVT) receiving intravenous heparin is to prevent bleeding. Heparin is an anticoagulant medication used to prevent the formation of blood clots, but one of its potential side effects is bleeding due to its ability to prevent blood clotting. It is crucial to closely monitor the client for signs of bleeding while on heparin therapy, such as easy bruising, black or tarry stools, blood in the urine, or excessive bleeding from wounds. Preventing bleeding is essential to avoid complications associated with anticoagulant therapy.

Correct Answer: B

Rationale: Paroxysmal nocturnal dyspnea is a symptom commonly seen in patients with congestive heart failure (CHF). It is characterized by sudden awakening from sleep due to difficulty breathing and feeling of suffocation. This occurs because when the patient lies down, the redistribution of fluid in the body leads to increased fluid in the lungs, causing difficulty in breathing. Patients with CHF often experience worsening of symptoms at night, including paroxysmal nocturnal dyspnea, due to the shift in fluid dynamics in a supine position. Therefore, the client in this scenario is likely experiencing paroxysmal nocturnal dyspnea, a classic symptom of heart failure exacerbation.

Correct Answer: D

Rationale: Terazosin is an alpha-1 adrenergic receptor blocker. By blocking alpha-1 receptors in the vascular smooth muscle, terazosin causes dilation of both arteries and veins, leading to reduced peripheral vascular resistance and decreased blood pressure. This dilation effect is achieved by preventing the binding of norepinephrine to alpha-1 receptors, thereby inhibiting vasoconstriction. Terazosin is commonly used in the treatment of hypertension to help lower blood pressure by reducing the workload on the heart and improving blood flow to organs and tissues.

Correct Answer: A

Rationale: In the case of an adult client experiencing paroxysmal supraventricular tachycardia, the appropriate nursing intervention of initiating oxygen therapy is crucial. This is because adequate oxygenation helps optimize cardiac function and tissue perfusion during episodes of tachycardia. Oxygen therapy supports the myocardium and helps prevent complications associated with increased heart rate. Preparing for cardioversion is not indicated in this scenario as paroxysmal supraventricular tachycardia does not typically require cardioversion unless it is hemodynamically unstable. Beginning anticoagulation therapy is also not necessary for this condition unless there are other indications present. Administering intravenous adenosine is a treatment option for paroxysmal supraventricular tachycardia; however, it is usually done under medical supervision and not a primary nursing intervention. From an educational perspective, it is important for nurses to understand the rationale behind each intervention to provide safe and effective care to patients. Recognizing the appropriate interventions based on the specific condition helps nurses prioritize care and promote positive patient outcomes. This case highlights the significance of critical thinking and clinical reasoning in nursing practice, emphasizing the importance of evidence-based interventions tailored to individual patient needs.