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. Obtaining an ECG is important but not the first action. The priority is to stop activity, as exertion can worsen myocardial oxygen demand.
B. Having the client sit down immediately is correct. Stopping activity reduces cardiac workload and oxygen demand, preventing further ischemia or infarction.
C. Assessing vital signs is important but should follow stopping activity. Chest pain requires immediate action to reduce cardiac strain.
D. Administering sublingual nitroglycerin is appropriate but should be done after ensuring the client is seated. This prevents hypotension and syncope from occurring while standing.

A. The client holds his breath for 10 seconds after inhaling the medication. B. The client waits 10 min between inhalations. C. The client takes a quick inhalation while releasing the medication from the inhaler. D. The client exhales as the medication is released from the inhaler.

Correct Answer is A

Explanation

A. Holding the breath for 10 seconds after inhaling allows the medication to be absorbed into the lungs effectively.
B. The client should wait at least 1 minute between inhalations if a second dose is needed, not 10 minutes.
C. The client should take a slow, deep breath while releasing the medication to ensure better lung deposition.
D. The client should inhale while pressing the inhaler, not exhale, to properly receive the medication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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