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 C

Explanation

A. Neurologic status is important to monitor but is not directly related to evaluating calcium gluconate's effect on hyperkalemia.

B. Urine volume would not directly reflect the immediate effects of calcium gluconate in managing hyperkalemia.

C. Calcium gluconate is given to protect the heart from the effects of hyperkalemia by stabilizing the cardiac membrane. Monitoring the cardiac rhythm is essential to assess the effectiveness of the treatment.

D. The calcium level is relevant for monitoring the calcium treatment, but cardiac rhythm is a more immediate indicator of its effectiveness.

A. Client with a blood pressure of 90/50 mm Hg. B. Client with a temperature of 96° F (35.6° C). C. Client with a pulse of 118 beats/min. D. Client with a respiratory rate of 6 breaths/min.

Correct Answer is D

Explanation

A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.

B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.

C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.

D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.

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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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