A client who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as

Orthopnea

paroxysmal nocturnal dyspnea

pulsus alternans

acute bilateral pleural effusion

Answer and Explanation

The Correct Answer is B

A. Orthopnea: Orthopnea is difficulty breathing when lying flat, but the client's description of waking up suddenly points to paroxysmal nocturnal dyspnea.

B. Paroxysmal nocturnal dyspnea: This is the correct answer. Paroxysmal nocturnal dyspnea occurs when a client with heart failure wakes up at night feeling suffocated due to fluid redistribution and pulmonary congestion.

C. Pulsus alternans: Pulsus alternans refers to alternating strong and weak heartbeats and is not related to the client's description of nocturnal dyspnea.

D. Acute bilateral pleural effusion: While pleural effusion can cause respiratory symptoms, paroxysmal nocturnal dyspnea is more specific to heart failure.

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Correct Answer is D

Explanation

A. Multiple abdominal drains increase infection risk.

B. Cellulitis poses a high risk of infection.

C. Viral pneumonia is contagious and poses a high infection risk.

D. Chronic heart failure does not pose an infection risk, making this the safest roommate choice.

A. Insert a foley catheter. B. Schedule a pelvic magnetic resonance imaging test. C. Infuse normal saline at 50 ml/hr. D. Draw blood for a complete blood count.

Correct Answer is A

Explanation

A. The primary concern in this scenario is urinary retention, which can lead to kidney dysfunction (indicated by elevated BUN and creatinine). The priority intervention is relieving the retention by inserting a Foley catheter, which will help restore normal urinary output and prevent further complications.

B. MRI is not an immediate priority when the client is at risk for kidney damage due to urinary retention.

C. While IV fluids may be necessary, the first priority is relieving the obstruction causing urinary retention.

D. Drawing blood is important for assessing the client's condition but is not as urgent as managing urinary retention.

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A client who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client should the nurse assign as a roommate for a client who has aplastic anemia?

Correct Answer is D

Explanation

A client who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

Correct Answer is A

Explanation

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