A client with a history of heart failure presents with progressive shortness of breath over the last several days. Upon assessment, the nurse notes jugular venous distention, crackles in the lung bases auscultated bilaterally, and a bounding pulse. Which of the following interventions would be the nurse's priority?

Administration of IV antibiotics

Administration of IV diuretics

Isotonic intravenous fluids

Lay the client supine with legs elevated

Answer and Explanation

The Correct Answer is B

A. Administration of IV antibiotics is not appropriate for this client, as there is no indication of an infection. The client's symptoms are consistent with fluid overload due to heart failure, not an infectious process.
B. Administration of IV diuretics is the priority intervention. The client is exhibiting signs of fluid overload, including jugular venous distention, crackles, and a bounding pulse. IV diuretics, such as furosemide, help reduce fluid volume, alleviate pulmonary congestion, and improve breathing.
C. Isotonic intravenous fluids would exacerbate the fluid overload and worsen the client's symptoms. This intervention is contraindicated in this scenario.
D. Laying the client supine with legs elevated is inappropriate for a client with heart failure and fluid overload, as it can increase venous return to the heart and worsen pulmonary congestion. Instead, the client should be positioned upright to improve breathing.

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Correct Answer is B

Explanation

A. While having the son verify understanding may seem appropriate, using a family member as a translator is not acceptable for informed consent due to the potential for miscommunication or bias.
B. Contacting the hospital translator ensures accurate and professional communication. A certified translator is required for legal and ethical reasons to ensure the patient fully understands the procedure, risks, and benefits.
C. Using the son to clarify questions may lead to inaccuracies or incomplete understanding. Professional translation services must be utilized in medical settings.
D. The son does not need to sign the consent form. The provider must ensure the patient understands the procedure, and the consent form is signed by the patient or their legal representative after professional translation.

A. Ascending muscle weakness B. Muscle tetany and hyperreflexia C. Poor turgor and dry mucous membranes D. Bradycardia and hypotension

Correct Answer is C

Explanation

A. Ascending muscle weakness is more characteristic of hypokalemia (low potassium levels) rather than hypernatremia.
B. Muscle tetany and hyperreflexia are typically seen in hypocalcemia (low calcium levels) or hypomagnesemia (low magnesium levels), not hypernatremia.
C. Hypernatremia (high sodium levels) commonly causes dehydration, which results in poor skin turgor and dry mucous membranes. This is a key clinical sign of hypernatremia.
D. Bradycardia and hypotension are more commonly associated with hypovolemia (low blood volume) or hypotension, but they are not specific to hypernatremia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which assessment finding is most indicative of hypernatremia?

Correct Answer is C

Explanation

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