A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first?
Assess the client's respiratory status.
Ask the client about current medications.
Administer intravenous furosemide.
Draw blood to assess the client's serum electrolytes.
The Correct Answer is A
A. Assessing respiratory status is the priority in heart failure exacerbation, as respiratory distress can rapidly worsen and affect oxygenation.
B. While knowing current medications is important, the priority in this situation is addressing the client's respiratory needs.
C. Administering furosemide is part of the management plan but should follow the initial assessment of the client's condition, especially respiratory status.
D. Drawing blood is helpful but not the immediate priority in managing acute heart failure exacerbation.
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Related Questions
Correct Answer is C
Explanation
A. Blood glucose elevation is a concern for statins, but it is not a primary reason for questioning the order.
B. A history of high cholesterol is common and would not trigger concern regarding lovastatin.
C. Lovastatin can cause liver toxicity, so elevated liver enzymes are a contraindication or cause for concern when prescribing this medication. The nurse should verify this before starting the medication.
D. A history of peptic ulcers is unrelated to the use of lovastatin and would not be a concern in this case.
Correct Answer is A
Explanation
A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.
B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.
C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.
D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.
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