A client with a history of emphysema and heart failure is admitted to the emergency department with enema, coughing, and shortness of breath. The client's laboratory value for brain natriuretic peptide is elevated. Which prescription is most important for the nurse to implement?

Administer IV furosemide.

Insert an indwelling urinary catheter.

Monitor for telemetry ST segment changes.

Give a bronchodilator per inhaler.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering IV furosemide (a diuretic) is crucial for managing the client's symptoms of fluid overload, as indicated by enema and elevated brain natriuretic peptide (BNP) levels. Furosemide helps reduce the volume of fluid in the body, relieving symptoms of heart failure and improving breathing. It addresses the most urgent need for the client.

Choice B reason: Inserting an indwelling urinary catheter might be necessary for accurate measurement of urine output, especially in a client receiving diuretic therapy. However, it is not the most immediate intervention needed to stabilize the client's condition.

Choice C reason: Monitoring for telemetry ST segment changes is important for clients with cardiac conditions. While it is necessary for ongoing assessment, it does not address the immediate need to relieve fluid overload and improve the client's respiratory status.

Choice D reason: Giving a bronchodilator per inhaler can help with respiratory symptoms related to emphysema. However, in this scenario, the primary issue is fluid overload due to heart failure, which needs to be addressed first with diuretic therapy.

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 A

Explanation

Choice A reason: Determining if the client is using an inhaler before exercising is the most immediate and relevant action. Inhalers, particularly bronchodilators, can help prevent exercise-induced bronchoconstriction by relaxing the airway muscles and reducing mucus production.

Choice B reason: Assessing the client for signs and symptoms of upper airway infection is important but may not be directly related to the episodes triggered by exercise. This action might be more appropriate if there are other indications of infection.

Choice C reason: Reviewing the client's routine asthma management prescriptions is a good practice, but it should come after addressing the immediate concern of managing exercise-induced symptoms. Ensuring proper inhaler use can have a more immediate impact.

Choice D reason: Teaching the client to use pursed-lip breathing when episodes occur is useful for managing dyspneal but does not address the prevention of exercise-induced bronchoconstriction as effectively as using an inhaler.

A. Review the client's fluid intake prior to bedtime. B. Obtain a fingerstick blood glucose level. C. Collect a urine specimen for culture analysis. D. Palpate the bladder above the symphysis pubis.

Correct Answer is D

Explanation

Choice A reason: Reviewing the client's fluid intake prior to bedtime is important for managing nocturia, but it does not address the immediate concern of urinary retention and difficulty starting the urinary stream.

Choice B reason: Obtaining a fingerstick blood glucose level is relevant for diagnosing diabetes, which can cause increased urination. However, it does not directly address the current urinary symptoms.

Choice C reason: Collecting a urine specimen for culture analysis can help identify a urinary tract infection, but it does not provide immediate assessment information regarding the client's bladder status.

Choice D reason: Palpating the bladder above the symphysis pubis is the most immediate and relevant intervention. This assessment helps determine if the bladder is distended, indicating urinary retention, which is a common issue in older adult males and can cause the symptoms described.

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 history of emphysema and heart failure is admitted to the emergency department with enema, coughing, and shortness of breath. The client's laboratory value for brain natriuretic peptide is elevated. Which prescription is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. Which action should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

A client with chronic venous insufficiency is being discharged from the hospital and plans to return home. Which client statement indicates an understanding of home care instructions?

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

The nurse plans to provide diet instructions to a client who was recently diagnosed with diverticulosis. Which dietary modification should the nurse include in the teaching plan?

A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide the client?

A client with Crohn's disease is admitted to the medical unit with a three-day history of abdominal cramping, nausea, and vomiting. Which prescription should the nurse implement first?

Which diet modification should the nurse suggest to a client who was recently diagnosed with diverticulitis?

The home health nurse is caring for a client with Parkinson's disease who is beginning to experience swallowing difficulties. Which intervention should the nurse include in this client's plan of care?