A client with a history of heart failure presents to the emergency department with elevated blood pressure, dyspnea and bilateral crackles throughout lung fields. Which intervention would the nurse implement first?

Review I&O

Check pulse oximetry

Administer digoxin

Obtain 12-lead ECG

Answer and Explanation

The Correct Answer is B

a. Review I&O (Intake and Output): While reviewing intake and output is an essential component of assessing fluid status in heart failure, it is not the immediate priority in this scenario. The client's presentation with dyspnea and crackles suggests acute respiratory distress, which requires immediate assessment and intervention to address potential hypoxemia.

b. Check pulse oximetry: In a client presenting with elevated blood pressure, dyspnea, and bilateral crackles throughout lung fields, the priority intervention is to assess oxygenation status. Checking pulse oximetry provides immediate information about the client's oxygen saturation levels, which is crucial for determining the severity of respiratory distress and guiding subsequent interventions. Hypoxemia is a common complication in heart failure exacerbations and can worsen symptoms such as dyspnea and respiratory distress.

c. Administer digoxin: Digoxin is a medication commonly used in the management of heart failure to improve cardiac output and reduce heart rate. However, it is not the priority intervention in this scenario. Assessing oxygenation status and addressing respiratory distress take precedence over administering medications.

d. Obtain 12-lead ECG: While obtaining a 12-lead ECG is important for assessing cardiac rhythm and identifying any potential cardiac abnormalities, it is not the immediate priority in this scenario. The client's presentation with acute respiratory distress warrants immediate assessment of oxygenation status to guide appropriate interventions.

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Correct Answer is A

Explanation

Rheumatic fever: This inflammatory condition can affect various parts of the heart, including the mitral and aortic valves. Repeated episodes of rheumatic fever can lead to scarring and thickening of the heart valves, eventually causing stenosis (narrowing) of the mitral or aortic valve.

b. Endocarditis: This infection of the heart lining or valves can damage the structures, but it's not as directly linked to both mitral and aortic stenosis as rheumatic fever.

c. Marfan’s syndrome:Marfan syndrome is a genetic disorder that can affect connective tissue throughout the body, including the heart valves. It is commonly associated with aortic root dilatation and aortic regurgitation rather than aortic stenosis. While aortic valve involvement can occur in Marfan syndrome, it is not typically associated with mitral stenosis.

d. Female gender: While gender differences exist in the prevalence of certain cardiovascular conditions, such as rheumatic heart disease affecting more females than males, gender alone is not a significant risk factor for the development of either mitral or aortic stenosis.

A. Use a soft bristle toothbrush B. Risk of infection is increased C. Check for black, tarry stools D. Limit aspirin to 650mg/day E. Keep appointments for PT/INR monitoring

Correct Answer is ["A","C","E"]

Explanation

a. Use a soft bristle toothbrush: Warfarin (Coumadin) therapy can increase the risk of bleeding. Using a soft bristle toothbrush can help reduce the risk of gum bleeding or oral mucosal injury, which is important for clients on anticoagulant therapy.
b. Risk of infection is increased: There is no direct association between warfarin therapy and an increased risk of infection. This option is not relevant to warfarin therapy.
c. Check for black, tarry stools: Warfarin therapy increases the risk of gastrointestinal bleeding. Black, tarry stools can indicate upper gastrointestinal bleeding, which requires immediate medical attention.
d. Limit aspirin to 650mg/day: Aspirin is typically avoided or used cautiously in combination with warfarin due to an increased risk of bleeding. However, there is no specific recommended limit of 650mg/day for aspirin use in conjunction with warfarin. This option does not accurately reflect guidance for warfarin therapy.
e. Keep appointments for PT/INR monitoring: Prothrombin time (PT) and international normalized ratio (INR) monitoring are essential for assessing the effectiveness and safety of warfarin therapy. PT/INR levels need to be within the therapeutic range to prevent both clotting and bleeding complications. Keeping appointments for monitoring ensures timely adjustments to the warfarin dosage.

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A client with a history of heart failure presents to the emergency department with elevated blood pressure, dyspnea and bilateral crackles throughout lung fields. Which intervention would the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is a risk factor common to development of both mital and aortic stenosis?

Correct Answer is A

Explanation

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Correct Answer is ["A","C","E"]

Explanation

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