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. Adenosine 6 mg IV push: Adenosine is used for certain supraventricular tachycardias, but immediate cardioversion is the first priority for a client with atrial flutter and chest pain.

B. Immediate cardioversion: This is the correct answer. Immediate cardioversion is indicated for atrial flutter with signs of hemodynamic instability, such as chest pain and shortness of breath.

C. Adenosine 12 mg IV push: Adenosine may be used after the first dose of 6 mg if the initial dose was ineffective, but cardioversion takes precedence for unstable patients.

D. Amiodarone 150 mg bolus followed by a 24-hour drip: Amiodarone is an antiarrhythmic used for rate control or rhythm conversion but is not the first step for hemodynamically unstable clients with atrial flutter.

A. Ask Mrs. Smith where her husband is right now. B. Explain that the chart must contain an error. C. Apologize and declare confusion about the client. D. Ask the client about preferred forms of address.

Correct Answer is D

Explanation

A. Assuming the client is someone else's spouse based on a name may be inappropriate and could lead to misunderstanding.

B. The chart may not necessarily contain an error, and jumping to conclusions could be unprofessional.

C. Apologizing and declaring confusion may make the client uncomfortable. It's more respectful to inquire directly.

D. Asking the client about their preferred form of address is the most respectful and professional approach.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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