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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Testing the equipment with a smaller shock is unnecessary when preparing to defibrillate in an emergency.
B. Epinephrine is used in cases of cardiac arrest with no pulse, particularly in asystole or pulseless electrical activity (PEA), not immediately before defibrillation in ventricular fibrillation.
C. Synchronous mode is used for cardioversion, not for defibrillation. Defibrillation should be delivered in unsynchronized mode.
D. Before delivering a shock, it is essential to ensure that everyone, including the nurse, is clear of the client and any conductive surfaces like the bed. This prevents injury from the electrical shock.
Correct Answer is ["A","B","C"]
Explanation
A. Early menarche increases lifetime exposure to estrogen, raising breast cancer risk.
B. Age is a significant risk factor for breast cancer.
C. Genetic factors, like BRCA mutations, increase the risk.
D. History of multiple births is generally protective against breast cancer.
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