A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Volume of pedal pulses.

Length of capillary refill.

Rhythm of apical pulse.

Degree of skin elasticity.

Answer and Explanation

The Correct Answer is C

Rationale

A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.

B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.

C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.

D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.

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Correct Answer is A

Explanation

Rationale

A. This is because preventing falls and injuries is crucial for individuals with osteoporosis, as their bones are more fragile and susceptible to fractures. Creating a safe environment by identifying and resolving home safety hazards can significantly reduce the risk of falls, which is essential for the well-being of someone with osteoporosis.

B. Constipation can be a concern for older adults, especially those with limited mobility. While addressing constipation is important for overall comfort and well-being, it is not directly related to osteoporosis management.

C. Understanding risk factors for osteoporosis is important for prevention and management but not of immediate concern.

D. Adequate calcium intake helps maintain bone density and reduce the risk of fractures in individuals with osteoporosis. However, this is not a priority.

A. Ask the client's friend to sign the informed consent since the client is unresponsive. B. Notify the unit manager that an emergency court order is needed to allow surgery. C. Carry on with surgical preparation of the client without a signed informed consent. D. Continue to provide life support until a thorough search for a guardian is completed.

Correct Answer is C

Explanation

Rationale

A. The client's friend may not legally be authorized to provide consent unless they hold medical power of attorney or legal guardianship for the client. Without documentation of such authority, the friend cannot sign the informed consent.

B. In emergency situations where a patient lacks decision-making capacity and there is no available legal guardian or next of kin to provide consent, hospitals may seek a court order to proceed with necessary treatment. However, this could delay emergency treatment.

C. This is based on the legal and ethical understanding that saving the patient's life takes precedence when immediate action is required and consent cannot be obtained.

D. Providing life support ensures that the client's immediate medical needs are addressed while efforts are made to locate a legal guardian. However, unavailability of next of kin should not delay definitive intervention

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A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

Correct Answer is A

Explanation

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Correct Answer is C

Explanation

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