A nurse admits a patient who is experiencing an exacerbation of heart failure. Drag and drop in order of priority actions.

Administer the prescribed intravenous furosemide (Lasix).

Ask the patient about an advanced directive

Assess the client's respiratory status.

Draw blood to assess the patient's serum electrolytes.

Answer and Explanation

The Correct Answer is C,D,A,B

Choice A reason: Assessing the client's respiratory status is the top priority action. This ensures that any immediate issues with breathing or oxygenation are identified and managed promptly. Respiratory status can quickly deteriorate in patients with heart failure, and addressing this first can be life-saving.

Choice B reason: Drawing blood to assess the patient's serum electrolytes is important to determine any imbalances that need immediate correction. Electrolyte levels can affect heart function and overall stability, so understanding the patient's current status helps guide further treatment.

Choice C reason: Administering the prescribed intravenous furosemide (Lasix) is critical for managing fluid overload in heart failure. Furosemide helps reduce fluid retention and alleviate symptoms such as pulmonary edema, which can improve respiratory status and overall comfort.

Choice D reason: Asking the patient about an advanced directive is important for understanding their wishes and planning care accordingly. However, it is not an immediate priority compared to stabilizing the patient's respiratory status and addressing urgent medical needs.

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Correct Answer is B

Explanation

Choice A reason: Percutaneous Coronary Intervention (PCI) is a procedure used to open narrowed coronary arteries, usually with a balloon or stent. It is not a diagnostic test for assessing heart valves but rather a treatment for coronary artery disease.

Choice B reason: Echocardiography is a non-invasive imaging test that uses ultrasound waves to create detailed images of the heart's structures, including the heart valves. It allows for the assessment of valve function, structure, and blood flow, making it an essential tool for diagnosing valvular heart disease.

Choice C reason: Exercise testing, also known as a stress test, evaluates the heart's response to physical activity. While it can provide information on how well the heart handles increased workload and detect issues like ischemia, it is not specifically used for assessing heart valves.

Choice D reason: Electrocardiography (ECG or EKG) records the electrical activity of the heart and is used to detect arrhythmias, heart attacks, and other cardiac conditions. However, it does not provide detailed information about the heart valves' structure or function.

A. Hepatomegaly. B. Splenomegaly. C. Anuria. D. Ecchymosis.

Correct Answer is D

Explanation

Choice A reason: Hepatomegaly, or enlarged liver, is not a typical finding in DIC. While DIC can affect multiple organs due to widespread microvascular thrombosis and bleeding, hepatomegaly is more commonly associated with other conditions such as liver diseases or congestive heart failure.

Choice B reason: Splenomegaly, or enlarged spleen, is also not a common finding in DIC. Although the spleen can be involved in various hematologic disorders, DIC primarily affects the coagulation and fibrinolytic systems, leading to bleeding and clotting issues rather than spleen enlargement.

Choice C reason: Anuria, or absence of urine production, can occur in severe cases of DIC due to acute kidney injury from microvascular thrombosis or bleeding. However, it is not as common a finding as petechiae, bleeding gums, and ecchymosis. Anuria indicates a critical state requiring immediate intervention but is not the primary expected finding in DIC.

Choice D reason: Ecchymosis, or bruising, is a common finding in DIC. DIC involves widespread activation of the coagulation cascade leading to the consumption of clotting factors and platelets, resulting in bleeding manifestations such as petechiae, bleeding gums, and ecchymosis. These signs indicate the body's inability to form stable clots and the presence of spontaneous bleeding.

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A nurse admits a patient who is experiencing an exacerbation of heart failure. Drag and drop in order of priority actions.

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Naxlex Comprehensive Predictor Exams

The healthcare provider recommends to a patient that diagnostic testing be performed to assess for valvular heart disease. The nurse teaches the patient about which test that is commonly used to assess the valves?

Correct Answer is B

Explanation

The nurse is caring for a patient in shock with disseminated intravascular coagulation (DIC) and would expect to see the following assessments: petechiae, bleeding gums, and

Correct Answer is D

Explanation

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