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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Lantus insulin does not directly affect potassium levels in the same way that digoxin does.

B. A potassium level of 3.0 mEq/L is low, and digoxin toxicity can occur when potassium levels are low, leading to an increased risk of arrhythmias. This requires immediate attention to avoid serious complications.

C. Metoprolol is a beta-blocker that does not directly cause hypokalemia and is less of an immediate concern.

D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that could affect kidney function but does not directly impact potassium levels as significantly as digoxin.

A. "The client meets the criteria for the chronic asymptomatic HIV infection phase." B. "The clients CD4+ T cell count is within normal range." C. "The client meets the criteria for the acute HIV infection phase." D. "The client has developed Acquired Immunodeficiency Syndrome (AIDS)."

Correct Answer is D

Explanation

A. Chronic asymptomatic HIV infection refers to a phase with no opportunistic infections and higher CD4+ counts.

B. A CD4+ T cell count below 200 cells/μL is abnormal and diagnostic of AIDS, not within the normal range.

C. The acute HIV infection phase occurs shortly after exposure, characterized by flu-like symptoms and high viral load, not opportunistic infections.

D. The presence of Pneumocystis jiroveci pneumonia (an AIDS-defining illness) and a CD4+ T cell count below 200 cells/μL confirms a diagnosis of AIDS.

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A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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