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 D

Explanation

A. Ensuring that the IV solution is infusing at the prescribed rate is an important task to maintain adequate fluid and electrolyte balance, especially if the client is experiencing signs of shock or low blood pressure. However, this action alone does not address the immediate need to assess or intervene for potential critical issues such as bleeding or severe hemodynamic instability.
B. Listening to lung sounds can help assess for pulmonary complications, such as fluid accumulation or atelectasis, which can be relevant postoperatively. However, in the context of hypotension, tachycardia, and altered mental status, the priority is to address potential critical issues related to circulatory stability and bleeding.
C. It is essential to inform the healthcare provider of the client's condition, but this should be done after initial interventions to stabilize the client. This action is necessary but not the first priority.
D. The first action should be to check for any signs of bleeding, especially after abdominal surgery where internal bleeding is a possibility.

A. Stone fragments are collected when straining the client's urine. B. Client denies urinary frequency, urgency, or dysuria. C. Urine is pale pink with no observable blood clots. D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.

Correct Answer is A

Explanation

A. This directly indicates that the lithotripsy procedure was successful in breaking down the stone into smaller fragments that can be passed through the urinary tract.
B. While the absence of these symptoms is a positive sign, it does not directly confirm the success of the lithotripsy procedure. These symptoms can be present even if the stone has been broken down.
C. Pale pink urine is expected after lithotripsy due to minor bleeding. The absence of blood clots is also a good sign, but it doesn't definitively confirm the procedure's success.
D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits. These lab values are important indicators of kidney function but do not directly relate to the success of the lithotripsy procedure itself.

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Naxlex Comprehensive Predictor Exams

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

Correct Answer is D

Explanation

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

Correct Answer is A

Explanation

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

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The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse? Reference Range: Arterial Blood Gas (ABG) pH [7.35 to 7.45] PaCO, [35 to 45 mm Hg] HCO 21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg]

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

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Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?