The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports the diagnosis of acute heart failure exacerbation?

Question

The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure.  Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%.  Which of these findings supports the diagnosis of acute heart failure exacerbation?

Quizplus · Accepted Answer

Brain (or b-type) natriuretic peptide (BNP) is secreted in response to ventricular stretch and wall tension when cardiac filling pressures are elevated. The BNP level is used to differentiate dyspnea of heart failure from dyspnea of noncardiac etiology. The level of circulating BNP correlates with both severity of left ventricular filling pressure elevation and mortality. A normal BNP level is <100 pg/mL [<100 pmol/L]. The nurse would expect a high BNP in a client exhibiting symptoms of acute decompensated heart failure. (Option B) Jugular veins should normally flatten and disappear as the client is raised to an upright position. Jugular venous distension present above a 45-degree seated position indicates fluid volume excess and elevated cardiac filling pressures that occur with heart failure. (Option C) Normal sodium level is 135-145 mEq/L [135-145 mmol/L]. Serum sodium can be normal or low in heart failure clients. Low levels are due to dilution from excess free water. (Option D) Urine output of 100 mL/hr should be adequate to maintain fluid volume status. Inadequate urine output may cause fluid retention and volume overload, precipitating an exacerbation of heart failure. A state of low cardiac output may also decrease renal perfusion, resulting in renal dysfunction and decreased urine output. Diuretic therapy is the mainstay treatment for fluid volume overload. The nurse should expect to see an increase in urine output in response to diuretic administration. Educational objective: The nurse should assess the BNP level in clients admitted with heart failure exacerbations. Elevated BNP levels indicate increased ventricular stretch and correlate with severity of heart failure and fluid volume overload. Heart failure clients may also present with jugular venous distension, low serum sodium, and decreased urine output.

The Nurse Is Caring for a Client Who Has Been