A client with a diagnosis of heart failure is admitted to the cardiac unit. Which intervention should the nurse complete first?

Draw a basic metabolic panel (BMP) for a potassium level

Obtain a health history

Auscultate the lung and heart sounds

Assess the pulse and temperature

Answer and Explanation

The Correct Answer is C

A. Drawing a basic metabolic panel (BMP) is important for monitoring electrolyte imbalances, especially potassium in clients on diuretics, but it is not the priority intervention.
B. Obtaining a health history is necessary, but assessing the client’s current status takes priority in an acute setting.
C. Auscultating the lung and heart sounds is correct. In heart failure, pulmonary congestion and fluid overload can quickly lead to respiratory distress. The nurse should immediately assess for crackles, wheezing, or signs of pulmonary edema, as well as abnormal heart sounds that may indicate worsening heart failure.
D. Assessing pulse and temperature is routine, but assessing lung and heart sounds directly evaluates for acute decompensation and should be prioritized.

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Correct Answer is B

Explanation

A. Providing health recommendations is important, but the immediate concern is addressing the client's fear.
B. Encouraging the client to express emotions allows the nurse to assess and provide appropriate emotional support.
C. Dismissing the client's fears can make them feel unheard and may increase anxiety.
D. Referring the client to the physician too soon may shut down communication and miss an opportunity for emotional support.

A. Dizziness B. Crackles in the lungs C. Dry hacking cough D. Hepatomegaly

Correct Answer is D

Explanation

A. Dizziness is more commonly associated with left-sided heart failure due to decreased cardiac output and reduced cerebral perfusion.
B. Crackles in the lungs occur in left-sided heart failure due to pulmonary congestion. Right-sided heart failure primarily affects systemic circulation rather than the lungs.
C. A dry hacking cough is also a symptom of left-sided heart failure, resulting from fluid backup into the lungs.
D. Hepatomegaly is correct. Right-sided heart failure leads to systemic venous congestion, which can cause liver enlargement (hepatomegaly), ascites, and peripheral edema.

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A client with a diagnosis of heart failure is admitted to the cardiac unit. Which intervention should the nurse complete first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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