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 C

Explanation

A. Weight lifting can be beneficial for overall fitness, but for someone with chronic venous insufficiency, the focus should be on activities that improve venous return and avoid excessive strain on the legs. Heavy weight lifting might exacerbate symptoms or lead to further complications.
B. For individuals with chronic venous insufficiency, prolonged standing can worsen symptoms such as swelling and pain. It’s important to avoid standing for long periods and to use measures such as leg elevation and compression stockings to manage symptoms.
C. This statement reflects an understanding of good practices for managing chronic venous insufficiency. Sitting for prolonged periods and crossing the legs can impede venous return and worsen symptoms of CVI. It is advised to avoid these practices and instead frequently change positions, elevate the legs, and use compression stockings to improve circulation.
D. While getting help to walk a dog could be beneficial if the client is unable to walk or if walking exacerbates symptoms, this statement does not directly address key aspects of managing chronic venous insufficiency. Regular walking is generally recommended to enhance venous return and prevent complications, assuming it is done within the client’s tolerance and ability.

A. Prepare to administer a glucose, then insulin, then potassium infusion. B. Inform the healthcare provider of the need for potassium replacement. C. Instruct the client to Increase dally Intake of potassium rich foods. D. Change the plan of care to Include hourly urinary output measurements.

Correct Answer is B

Explanation

A. This action is typically used in the treatment of hyperkalemia (high potassium levels), not hypokalemia. The combination of glucose and insulin is used to temporarily drive potassium into cells and lower serum potassium levels. For severe hypokalemia, the priority is to administer potassium replacement therapy rather than attempting to lower potassium levels, as the client needs to correct the deficiency.
B. Severe hypokalemia requires prompt correction to prevent complications. Potassium replacement should be administered according to healthcare provider orders. This may involve oral or intravenous potassium supplements, depending on the severity of the hypokalemia and the client's condition. Informing the healthcare provider is essential for ensuring that appropriate and timely treatment is provided.
C. While increasing potassium intake through diet is important for managing mild cases of hypokalemia, a serum potassium level of 2.5 mEq/L is severe and likely requires immediate medical intervention. Dietary changes alone are insufficient and not timely enough to address such a critical deficiency.
D. Monitoring urinary output is important in managing electrolyte imbalances to assess kidney function and fluid balance, but it is not the primary intervention for severe hypokalemia. The immediate priority is to address the low potassium level through appropriate replacement therapy.

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Naxlex Comprehensive Predictor Exams

A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?

Correct Answer is C

Explanation

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

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