A client arrives on the cardiac unit from the emergency room with a diagnosis of heart failure exacerbation. The nurse receives the client who is acutely short of breath with respiratory rate of 40, pulse oximetry 85%, blood pressure 150/90, and lower extremity swelling. What intervention or action should the nurse take first?

Ensure the client is sitting in an upright position.

Call the respiratory therapist in anticipation of intubating the client.

Prepare to place a Foley catheter in anticipation of giving Lasix.

Apply oxygen.

Answer and Explanation

The Correct Answer is D

Choice A reason: Sitting upright improves breathing but doesn’t address the critical hypoxia indicated by 85% pulse oximetry. Applying oxygen directly corrects low oxygen levels, making this secondary and incorrect compared to the nurse’s priority of ensuring adequate oxygenation in a heart failure exacerbation.

Choice B reason: Calling for intubation anticipates worsening but is premature without first addressing hypoxia with oxygen. Applying oxygen is the immediate need, making this incorrect, as it bypasses the initial step of improving oxygenation in the client with severe respiratory distress.

Choice C reason: Preparing for a Foley catheter anticipates diuresis but doesn’t address the urgent hypoxia at 85% oxygen saturation. Applying oxygen is critical, making this incorrect, as it delays the primary intervention needed to stabilize the client’s respiratory status in heart failure.

Choice D reason: Applying oxygen is the first action to correct hypoxia (pulse oximetry 85%), improving tissue oxygenation in heart failure exacerbation. This aligns with acute care priorities, making it the correct intervention to address the client’s immediate respiratory distress and low oxygen saturation effectively.

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Correct Answer is C

Explanation

Choice A reason: Lithium can cause nephrogenic diabetes insipidus, not SIADH, which involves excess ADH. Lung cancer is a known SIADH trigger, making this incorrect, as it’s unrelated to the syndrome compared to the high-risk client with cancer and vincristine therapy.

Choice B reason: Losartan treats hypertension in renal artery stenosis but doesn’t cause SIADH, which is linked to cancers. Lung cancer with vincristine is riskier, making this incorrect, as it’s not associated with the syndrome in the nurse’s risk assessment of clients.

Choice C reason: Lung cancer, especially small cell, and vincristine are strongly associated with SIADH due to ectopic ADH production. This aligns with oncology risk factors, making it the correct client most at risk for SIADH in the nurse’s outpatient clinic care.

Choice D reason: Hyperthyroidism and methimazole don’t typically cause SIADH, unlike lung cancer’s strong link. Vincristine-treated cancer is the highest risk, making this incorrect, as it’s not a primary cause of SIADH in the nurse’s evaluation of the outpatient clients.

A. Nausea, vomiting, depression, fatigue, and impotence. B. Sedation, nausea, vomiting, constipation, and respiratory depression. C. Headache, hypotension, dizziness, and flushing. D. Flushing, dizziness, headache, and pedal edema.

Correct Answer is C

Explanation

Choice A reason: Nausea and vomiting may occur with nitroglycerin, but depression, fatigue, and impotence are unrelated. Headache and hypotension are primary effects, making this incorrect, as it includes irrelevant symptoms compared to the nurse’s teaching on nitroglycerin’s expected side effects.

Choice B reason: Sedation, constipation, and respiratory depression are opioid effects, not nitroglycerin, which causes vasodilation. Dizziness and flushing are correct, making this incorrect, as it misattributes opioid side effects to nitroglycerin in the nurse’s education for angina management.

Choice C reason: Nitroglycerin causes headache, hypotension, dizziness, and flushing due to vasodilation, common side effects. This aligns with pharmacological education for angina, making it the correct set of symptoms the nurse would teach the client to expect after taking sublingual nitroglycerin.

Choice D reason: Pedal edema is not a nitroglycerin side effect, though flushing, dizziness, and headache are. Hypotension is more precise than edema, making this incorrect, as it includes an unrelated symptom compared to the accurate side effects in nitroglycerin teaching.

Choice E reason: Decreased cardiac output and peripheral edema are not nitroglycerin effects; it improves coronary flow. Flushing is correct, but hypotension is key, making this incorrect, as it misrepresents nitroglycerin’s pharmacological effects in the nurse’s teaching for angina relief.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse cares for clients in the outpatient clinic. Which client is MOST at risk for the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items would the nurse include on this list? (Select all that apply)

A child has a 2-day history of vomiting, hypoactive bowel sounds, and an irregular pulse. Electrolyte values are sodium, 130 mEq/L; potassium, 3.3 mEq/L; calcium, 9.5 mg/dL; and HCO3, 30 mEq/L. Which of the following imbalances is the child most likely to have? (Select all that apply)

You are working on a busy unit and need to delegate tasks to the LPN and M

A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)

The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

Which situations are early signs of an ethical dilemma? (Select all that apply)