A nurse on a medical-surgical unit is caring for a client. Exhibits Complete the diagram by from the choices below to specify what condition the client vs most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation & Rationale
Potential Condition: Heart failure Rationale: The client presents with S3 heart sound, bilateral crackles, lower extremity edema +3, cool peripheral pulses, and BNP 350 ng/L (elevated). These findings are classic for heart failure, indicating volume overload and decreased cardiac output. Vital signs show tachycardia and borderline hypotension, consistent with compensatory mechanisms in heart failure. Actions to Take: Obtain a prescription for a diuretic to reduce fluid overload and manage edema and pulmonary congestion. Educate the client about sodium restriction: dietary sodium restriction helps prevent fluid retention and exacerbation of heart failure. Parameters to Monitor: Daily weight: rapid weight gain indicates fluid retention. Blood pressure: hypotension may indicate decreased cardiac output or over-diuresis; hypertension may worsen heart failure.