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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Immediately notify the provider . A rise in the water seal chamber with inspiration (tidaling) is a normal finding, indicating proper function of the chest drainage system. There is no need for immediate provider notification.
B. Clamp the chest tube near the water seal . Clamping the chest tube can lead to a tension pneumothorax by trapping air inside the pleural space. This action is only done temporarily for specific indications, such as assessing for an air leak or changing the drainage system.
C. Continue to monitor the client . Tidaling (fluctuation of water with inspiration and expiration) is expected in the water seal chamber. The nurse should continue to monitor for any sudden cessation of tidaling (which may indicate obstruction) or continuous bubbling (which may indicate an air leak).
D. Reposition the client toward the left side . Position changes do not affect normal tidaling in a functioning chest tube system. However, frequent repositioning is encouraged to promote lung expansion.

A. Sitting up leaning over the bedside table. B. Fowler's position in the bed. C. Sitting in a recliner. D. Prone in bed.

Correct Answer is A

Explanation

A. Sitting up and leaning over the bedside table (tripod position) helps maximize lung expansion, decreases work of breathing, and improves oxygenation in clients with COPD.
B. Fowler's position can help with breathing but does not provide as much relief as the tripod position.
C. A recliner may be comfortable but does not optimize lung expansion like the tripod position.
D. Lying prone is not beneficial for COPD patients and can make breathing more difficult.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is caring for a client who has a closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? Utilize image to see area that is being described.

Correct Answer is C

Explanation

The nurse knows that which of the following positions is the best position for a client diagnosed with COPD?

Correct Answer is A

Explanation

The nurse is providing education to a client on ways to prevent the development of a pulmonary embolism. Which of the following statements would require further teaching?

Why are small, frequent meals recommended for patients with Chronic Obstructive Pulmonary Disease (COPD)?

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

The nurse recognizes which of the following as a risk factor for obstructive sleep apnea?

The nurse is to administer heparin to a client who weighs 90 pounds. Heparin is ordered as 10,000 units/100mL. The nurse needs to administer a bolus of 40units/kg. How many units would the nurse administer? (Round to the nearest tenth)

Which of the following is considered a risk factor for COPD?

The nurse identifies which of the following as the most common cause of a myocardial infarction?