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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This instruction is particularly relevant for a client with gouty arthritis. Gout is a type of arthritis caused by elevated levels of uric acid in the blood, which can form crystals in the joints and cause severe pain and inflammation. Red meat and certain seafood are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
B. This instruction might not be suitable for someone with hypertension, as many salt substitutes contain potassium. For a person with high blood pressure, excessive potassium can be harmful, especially if they are on certain medications or have kidney issues.
C. This advice may not be appropriate given the client's current inability to bear weight due to severe ankle pain. Limiting mobility equipment could lead to further physical complications. The focus should be on managing pain and inflammation to improve mobility rather than restricting the use of equipment.
D. While wrapping joints with an elastic bandage can help reduce swelling, it should be done with caution. Over-wrapping can lead to decreased circulation or additional pain. In cases of severe pain and swelling, other treatments such as rest, elevation, and ice may be more appropriate.

A. First voided specimen in the morning. B. A clean catch specimen. C. Any specimen voided after drinking adequate fluids. D. A 24-hour specimen.

Correct Answer is B

Explanation

A. A first voided morning specimen is often used for detecting conditions such as urinary tract infections (UTIs) or pregnancy because it is more concentrated and may provide a clearer result. However, for diagnosing urethritis specifically, a clean catch or midstream specimen is generally preferred to minimize contamination and better identify pathogens.
B. A clean catch urine specimen is the most appropriate method for diagnosing urethritis. This method reduces the risk of contamination from bacteria that may be present in the initial or final part of the urine stream, providing a more accurate representation of the urine coming directly from the bladder.
C. Collecting any specimen after drinking fluids is not a standardized method for diagnosing urethritis. While adequate fluid intake is generally important for urine production and can help dilute the urine, the quality and accuracy of the specimen are more reliably ensured through specific collection techniques such as a clean catch.
D. A 24-hour urine collection is used for assessing the overall function of the kidneys and measuring substances that vary in concentration throughout the day, such as proteins or electrolytes. It is not typically used for diagnosing urethritis, which is usually evaluated with a clean catch specimen for a more immediate assessment of infection or inflammation.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?

Correct Answer is B

Explanation

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

Exhibits The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.

A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?

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.

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?

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?