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. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.

B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.

C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.

D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.

A. Heparin B. Morphine C. Propranolol D. Nitroglycerin E. Answer: C

Correct Answer is C

Explanation

A. Heparin is an anticoagulant and does not typically cause bronchospasm or wheezing.

B. Morphine can cause respiratory depression but not bronchospasm.

C. Propranolol, a non-selective beta-blocker, can cause bronchospasm, particularly in clients with asthma.

D. Nitroglycerin primarily causes vasodilation and does not typically lead to bronchospasm or wheezing.

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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

The post anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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