A client with heart failure is receiving intravenous fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider?

Observe for change in breathing pattern.

Palpate the volume of pedal pulses.

Assess for inflammation of the calves.

Inspect for distention of peripheral veins.

Answer and Explanation

The Correct Answer is A

Choice A reason: Increased JVD and pedal edema indicate fluid overload in heart failure, where reduced cardiac output causes venous congestion. Assessing breathing for dyspnea or crackles detects pulmonary edema, as fluid backs into alveoli, impairing gas exchange. This urgent finding guides interventions like diuretics, critical before reporting.

Choice B reason: Palpating pedal pulses assesses arterial flow, not fluid overload causing JVD and edema, which are venous issues in heart failure. Pulses may be normal despite congestion. Breathing changes indicate pulmonary edema, a life-threatening complication, making this assessment more critical for detecting acute decompensation.

Choice C reason: Assessing calf inflammation may detect thrombosis, a heart failure risk, but JVD and edema suggest fluid overload, not clotting. Breathing changes are more urgent, indicating pulmonary edema from alveolar fluid, requiring immediate intervention to prevent respiratory failure, unlike inflammation, which is less immediate.

Choice D reason: Inspecting peripheral vein distention confirms venous congestion but is less critical than breathing assessment. In heart failure, fluid overload risks pulmonary edema, where alveolar fluid causes dyspnea. Monitoring breathing detects this severe complication, prioritizing intervention to ensure oxygenation over additional venous assessment.

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

Explanation

Choice A reason: Monitoring airway and tongue during a tonic-clonic seizure is critical, as muscle contractions can obstruct the airway or cause tongue biting, leading to hypoxia. Ensuring airway patency prevents respiratory compromise, a life-threatening issue, addressing the physiological priority of oxygenation during seizure-induced neuronal hyperactivity.

Choice B reason: Darkening the room by closing blinds is not a priority during a seizure. Reducing stimuli may help photosensitive epilepsy, but active seizures require airway and safety management. Uncontrolled movements from neuronal discharges pose immediate risks, making airway monitoring and injury prevention more critical than environmental adjustments.

Choice C reason: Placing pillows inside side rails protects the child from trauma during a seizure, as tonic-clonic movements from cortical hyperexcitability risk fractures or head injuries. Padding reduces impact injuries, addressing the physiological need for safety during clonic jerking, ensuring protection against environmental hazards in the seizure setting.

Choice D reason: Asking the mother to release the child prevents harm, as restraint during a seizure can cause fractures or muscle strain by resisting neuronal-driven movements. Allowing free movement in a safe environment reduces injury risk, prioritizing physical safety and preventing complications from external resistance during the seizure.

Choice E reason: Administering an anticonvulsant requires a prescription and is not immediate during an active seizure. While drugs like lorazepam treat prolonged seizures, the nurse prioritizes airway and safety. Only trained personnel with orders can administer medications, making this less urgent than ensuring airway patency and injury prevention.

A. A client with pancreatitis who has a fasting glucose of 190 mg/dL (10.55 mmol/L) today and had 160 mg/dL (8.88 mmol/L) yesterday. B. A client with a gastrointestinal (GI) bleed who is receiving a blood transfusion and has a hemoglobin of 7.0 g/dL (4.34 mmol/L). C. A client with cancer who has an absolute neutrophil count (ANC) of less than 500/mm3 today and had 2,000/mm3 yesterday. D. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.

Correct Answer is C

Explanation

Choice A reason: Elevated glucose (190 mg/dL) in pancreatitis needs monitoring but is less urgent than severe neutropenia (ANC <500/mm3), which risks life-threatening infections. Glucose can be managed with insulin, per diabetes and pancreatitis care protocols, but neutropenia requires immediate intervention.

Choice B reason: Hemoglobin of 7.0 g/dL in a GI bleed is critical but less immediate, as the client is receiving a transfusion. Neutropenia (ANC <500/mm3) poses an urgent infection risk, requiring isolation. Transfusion addresses anemia, per bleeding and hematology care standards.

Choice C reason: An ANC <500/mm3 indicates severe neutropenia, posing an immediate infection risk in cancer patients, requiring urgent isolation and antibiotics. This rapid drop from 2,000/mm3 demands priority intervention to prevent sepsis, per oncology and infection control protocols in nursing practice.

Choice D reason: Elevated bilirubin in hepatitis is concerning but less urgent than neutropenia (ANC <500/mm3), which risks sepsis. Jaundice requires monitoring and treatment, but severe infection risk takes precedence, per liver disease and critical care prioritization standards in nursing practice.

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A client with heart failure is receiving intravenous fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic-clonic seizure. The mother is hysterical and is trying to hold the child down. What action(s) should the nurse take? (Select all that apply)

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

Explanation

Which client’s laboratory value requires immediate intervention by a nurse? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

Correct Answer is C

Explanation

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