Walkthrough: Physiological Adaptation Q11 – NCLEX-RN®

00:01 A nurses caring for a client who has experienced a myocardial infarction in the past.

00:06 Which assessment findings most concern the nurse regarding congestive heart failure? Select all that apply. Okay, let's break it down.

00:14 So I'm a nurse, the RN.

00:16 Like why do you do that every time Prof. Lawes? Because trust me, you don't know if it's a delegation question or not.

00:22 And you really want to train your brain to orient yourself to who is in the question.

00:28 The nurse is an RN on the NCLEX-RN Exam.

00:31 So I have a nurse and a client.

00:34 Now what's particular about this client is they had a myocardial infarction, when? Well just tells us in the past, but here's what that last sentence is asking us.

00:45 Which assessment findings most concern the nurse regarding congestive heart failure? So are they talking about the MI? Not really.

00:54 Maybe the MI caused the damage, but the focus of the question is, which assessment findings most concern the nurse regarding congestive heart failure? Now, before you look at the answer choices, think about what you know about congestive heart failure.

01:10 Well, you know, that the heart isn't able to pump blood efficiently enough.

01:14 You know, they can have all kinds of symptoms.

01:17 Right sided failure can look different than left sided failure.

01:21 Some patients have systolic or diastolic.

01:23 Don't get lost in the weeds.

01:25 Just think about what you know, are the biggest problems, and it kind of groups itself into fluid management.

01:30 Let's take a look at the answer choices.

01:33 Number one. Chronically elevated blood pressure measurements.

01:39 Okay. Does that concern me with congestive heart failure? It does, because that means that heart is working extra hard.

01:47 So I'm going to select number one.

01:49 Number two, bilateral 3+ pitting edema on the lower extremities.

01:56 That is a sign of pretty significant right sided failure, because 3+ pitting edema is pretty significant.

02:03 So does that concern me for a CHF patient? Yes, check number two.

02:08 Number three. Left ventricular hypertrophy noted on the chest X ray? Well, that means that left ventricle that's trying to push blood out to the rest of the body starting to remodel and get bigger and it's probably not as efficient.

02:24 Is this a problem with CHF? Yes, that ejection fraction can be impacted.

02:30 So this would be another option that I would select.

02:33 I would be concerned about this regarding congestive heart failure.

02:37 Number four. Pulmonary edema noted on the chest X-ray.

02:43 Well, we know that happens because when that left side of the heart can't pump blood out efficiently, it's going to back up.

02:51 Now, work with me real quick.

02:53 Right atrium, right ventricle over to the lungs, then back to the left atrium, to the left ventricle and out to the body.

03:02 So when that left ventricle is weak, like it often is and congestive heart failure, fluid is going to back up.

03:09 Now, if it backs up from the left atrium, it's going to end up going into the lungs.

03:15 And that's what pulmonary edema is.

03:18 So watch for that one of the worst case scenarios with anyone in fluid volume overload, or in CHF is pulmonary edema. Why? Because if your lungs can't exchange CO2 and O2 very well, which they can't and pulmonary edema, that's going to affect the whole body.

03:35 So that may have been more than you're looking for in that answer.

03:38 But that's such an easy thing to miss.

03:41 I want to make sure you recognize pulmonary edema is one of the worst case scenarios with CHF, and nobody likes to swollen ankles.

03:49 But pulmonary edema has a much bigger negative impact on the rest of the body.

03:54 So, 1, 2, 3, 4, we've got the fifth answer left.

04:00 Number five. Evidence of a new myocardial infarction on cardiac cath.

04:06 Okay, no, there's a key word there.

04:08 We learned in the stem of the question that the client already had had a myocardial infarction.

04:14 But this tells us the patient has had further cardiac damage, because it's a new myocardial infarction.

04:22 So look for those adjectives.

04:24 They can give you clues that could make a total difference in the answer.

04:28 So number five, I'm going to check that one also.

04:31 I'm concerned with a client who already is in congestive heart failure, that heart is really struggling to be an adequate pump.

04:38 Now they've had another MI, and so this is going to make life even more difficult for them.

04:44 So looking back over the answer choices, I've checked all five of them.

04:48 I'm going to say the question again, in my mind, make sure I'm happy with my answer choices.

04:54 So would I be concerned about number one for a patient with congestive heart failure? Number two for a patient with congestive heart failure, and all the way through each of the answer options again, then I'm going to mark it on my screen and move on to the next question.

05:10 Hey, thanks for joining us for this question.

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