Question

Part 3

M.A. is a 65- year-old woman who presents to the emergency department complaining of shortness of breath, productive cough and swelling in both legs. The patient has a past medical history of congestive heart failure (CHF), hypertension, and diabetes. Vital signs are T 97.5, P 85, R 16, and BP 160/90. Physical Assessment reveals +2 edema bilateral lower extremities, heart rate and rhythm regular, and lungs with rhonchi in the bases. The patient is started on a nebulizer treatment, and an electrocardiogram has been ordered.

1. What subjective information should the nurse obtain?
2. The nurse is assessing the patient’s pulses. Which locations should the nurse check?
3. The nurse needs to evaluate the adequacy of the collateral circulation before obtaining an arterial blood gas (ABG) sample. How should the nurse proceed?
4. What is the most likely cause of this patient’s shortness of breath, productive cough, and swelling in both legs?

Answer 1