The nurse is caring for a client with decreased cardiac output. Which of the following nursing actions should the nurse implement to monitor this client?

Assess heart rate every hour and watch out for tachycardia.
Assess peripheral pulses for strength, quality, and for pulsus alternans.
Document rhythm strips every 8 hours and inform the physician if dysrhythmias occur.

Explanation

• Cardiac rhythm strips should be documented at least every 8 hours, and dysrhythmias reported for adequate cardiac management

• Common dysrhythmias include premature atrial contractions (PACs), premature ventricular contractions (PVCs), and paroxysmal atrial tachycardia (PAT). Changes in the ST segment may indicate myocardial ischemia from decreased coronary artery perfusion

• VS should be taken hourly, and tachycardia reported. Tachycardia can increase myocardial and oxygen demands and may be a compensatory mechanism related to the decreased cardiac output (increased heart rate to compensate for decrease in stroke volume). Assessment for this can help in prompt intervention

• Decreased strength of peripheral pulses is often found in clients with decreased cardiac output, and a further decrease in pulses from baseline may indicate further cardiac failure. Pulsus alternans indicates severe heart failure

• Oral care can help with the sensation of thirst without an increase in fluid intake. This promotes oral health maintenance but not cardiac pump effectiveness

• Diuretics are commonly prescribed to promote the diuresis of accumulated fluid in those with fluid volume overload

• Decreased systemic blood pressure can lead to stimulation of aldosterone, which leads to renal retention of sodium. A low-sodium diet is often prescribed to minimize water retention. This will not promote cardiac pump effectiveness

Visit our website for other NCLEX topics now!
Related questions

A newly licensed nurse was asked by her nurse preceptor about examples of malignant neoplasms. The nurse answers accurately by giving which of the following types of neoplasms:

The nurse is doing an admission assessment on a patient with a history of myocardial infarction. Which signs and symptoms of left-sided heart failure should the nurse look for?

A patient is seen in the clinic for a follow-up related to chronic gastritis. The nurse should be alert for which vitamin deficiency?

The nurse is providing instructions to a patient with a plaster cast on the left arm. To relieve itching under the cast, the patient should:

A nurse is caring for a client who underwent Total Hip Arthroplasty (THA) with the nursing diagnosis of impaired physical mobility related to pain and fear of movement. Which of following interventions are appropriate to address the client’s problem? 

The nurse is assessing a patient in Thomas splint traction, a device used to immobilize a hip fracture. The nurse should assess for complications as indicated by:

While caring for a patient who underwent a percutaneous transluminal coronary angioplasty (PTCA), the nurse prepares to remove the femoral sheath. The heparin infusion was stopped 4 hours ago and there appears to be no evidence of bleeding from the insertion site. The nurse will pull the sheath when the partial thromboplastin time (PTT) is:

A definitive diagnosis of Alzheimer's disease (AD) requires histopathologic examination which is rarely done. What tests will the nurse expect to be ordered to rule out other disorders?

The nurse is teaching an adult patient diagnosed with bladder cancer about the signs and symptoms of chemo-induced thrombocytopenia, which include: