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

a. BNP 700pg/ml (<100pg/ml)

Rationale: B-type natriuretic peptide (BNP) is a biomarker used to diagnose and assess the severity of heart failure. Elevated BNP levels indicate increased ventricular stretch and fluid overload, both of which are indicative of worsening heart failure. A BNP level of 700pg/ml is significantly elevated compared to the normal range (<100pg/ml) and suggests acute exacerbation or decompensation of heart failure, requiring prompt intervention and management adjustment.

b. Chest x-ray shows cardiomegaly: While cardiomegaly on chest x-ray is indicative of heart failure, it is a diagnostic finding rather than an acute result requiring immediate intervention. It would be important to address but may not require urgent reporting unless accompanied by acute symptoms.

c. Hematocrit 35% (37-47%): A hematocrit of 35% falls at the lower end. While changes in hematocrit can indicate fluid volume status, this value alone does not indicate an urgent need for intervention or adjustment of therapy. It may warrant monitoring over time, but it is not an immediate concern.

d. Echocardiogram with ejection fraction of 60% (normal is 55-75%): An ejection fraction of 60% falls within the normal range and is not indicative of worsening heart failure. While it's essential to monitor ejection fraction in heart failure patients, this result alone does not suggest acute decompensation requiring immediate intervention.

A. Check groin dressing B. Review current H&H C. Check blood glucose D. Assess pain level

Correct Answer is D

Explanation

a. Check groin dressing: While monitoring the dressing is important, it is not the top priority immediately after the procedure. The nurse should assess other critical aspects first.
b. Review current H&H (hemoglobin and hematocrit): Although monitoring hemoglobin and hematocrit levels is essential, it is not the highest priority at this moment. Immediate post-procedure concerns take precedence.
c. Check blood glucose: Blood glucose monitoring is important, especially if the client has diabetes or other risk factors. However, it is not the priority right after the procedure.
d. Assess pain level: This is the priority intervention. The nurse should assess the client’s pain level, especially at the insertion site. Pain could indicate complications such as bleeding, hematoma, or vascular injury.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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