A client is admitted to the emergency department 5 days after an acute coronary syndrome (ACS) troubled by severe fatigue, muscle weakness, and shortness of breath. The client's electrocardiogram (ECG) Indicates sinus tachycardia and the laboratory findings indicate an elevated serum brain natriuretic peptide (BNP) level. Which action is most important for the nurse to implement?

Insert an indwelling urinary catheter.

Obtain blood for serum cardiac enzymes.

Provide emotional support.

Auscultate lung fields for fine rales.

Answer and Explanation

The Correct Answer is D

A.   Inserting an indwelling urinary catheter may be considered if the client is unable to urinate or if precise measurement of urine output is crucial for assessing fluid status. However, in this context, the immediate concern is more likely related to the client's cardiovascular status and respiratory symptoms rather than urinary output.
B.   Serum cardiac enzymes (such as troponin, CK-MB) are important for diagnosing acute myocardial infarction or myocardial injury. While this is relevant for assessing cardiac damage, the elevated BNP level and current symptoms suggest that heart failure or fluid overload might be more pressing concerns.

C.   Emotional support is important for any patient, especially those dealing with significant health issues. However, in this situation, the priority should be on addressing the immediate physiological concerns related to the client's symptoms and laboratory findings. Emotional support can be provided alongside other clinical interventions but should not be the primary action in this acute setting.
D.   Fine rales (or crackles) in the lung fields are often associated with pulmonary congestion or fluid
overload, which are common in heart failure. Given the elevated BNP level and the client’s symptoms of
shortness of breath and fatigue, assessing the lung fields for rales is crucial.

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Correct Answer is B

Explanation

A. Spicy foods can exacerbate GERD symptoms by irritating the esophagus and increasing acid production. While minimizing spicy foods is important, it is one of several dietary changes that can help manage GERD. It’s beneficial but may not be the single most critical instruction compared to other lifestyle modifications.
B. Remaining upright after meals is crucial for managing GERD. Lying down or reclining too soon after eating can allow stomach acid to flow back into the esophagus, worsening symptoms. Staying upright helps to facilitate digestion and reduce acid reflux, making this practice highly important for symptom control and prevention of reflux.
C. Tight-fitting clothes can increase abdominal pressure, which may contribute to the occurrence of acid reflux. While this is a helpful instruction to prevent exacerbation of symptoms, it may not be as directly impactful as remaining upright after meals.
D. Smoking can weaken the lower esophageal sphincter (LES), making it easier for stomach acid to reflux into the esophagus. However, while important, this instruction might be considered a secondary priority compared to immediate practical strategies like maintaining an upright position after eating.

A. Neutrophil count. B. C-reactive protein level. C. Platelet count. D. Serum potassium and sodium levels.

Correct Answer is B

Explanation

A. While neutrophils are involved in the immune response and wound healing, they are more indicative of an acute infection. An increased wound size suggests a worsening chronic condition rather than an acute infection.
B. C-reactive protein (CRP) is a sensitive marker of inflammation. An increase in CRP often accompanies worsening inflammation, such as an increase in wound size. Evaluating CRP levels would provide valuable information about the overall inflammatory state of the client.
C. Platelets are involved in blood clotting and wound healing, but they are not directly related to the overall inflammatory process or wound size.
D. These electrolytes are important for overall health, but they are not directly related to wound healing or inflammation.

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Naxlex Comprehensive Predictor Exams

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

Correct Answer is B

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Correct Answer is B

Explanation

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?

A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

Exhibits The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding. Each row must have one option selected.