A nurse is admitting a client who has a history of heart failure.
Check the 5 findings that require immediate follow-up.
Vital signs
Respiratory assessment
Renal function
Cardiac enzymes
BNP
ECG results
Neurologic status
Correct Answer : A,B,C,E,F
A. Vital signs . The client has tachycardia (HR 138/min) and tachypnea (RR 28/min), which may indicate worsening heart failure or fluid overload. The low blood pressure (96/75 mmHg) is also concerning, especially with rapid ventricular response (RVR).
B. Respiratory assessment . The presence of a frequent cough with pink-tinged sputum suggests pulmonary congestion or pulmonary edema, a sign of worsening left-sided heart failure.
C. Renal function . The BUN of 28 mg/dL (elevated) and creatinine of 1.5 mg/dL (borderline high) suggest possible kidney impairment due to decreased cardiac output and poor perfusion.
D. Cardiac enzymes . The client denies chest pain or discomfort, so cardiac enzymes are not the immediate priority.
E. BNP (B-type natriuretic peptide) . BNP is a key marker of heart failure severity and helps guide treatment decisions.
F. ECG results . The atrial fibrillation with RVR increases the risk of hemodynamic instability and potential thromboembolic events, requiring urgent intervention.
G. Neurologic status . The client is alert, oriented, and following commands, so no immediate neurologic concerns are present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Preventing bronchospasms and promoting bronchodilation is correct. Ipratropium is an anticholinergic bronchodilator that relaxes airway muscles, reducing airway resistance and improving airflow in COPD patients.
B. Monitoring blood pressure is unrelated to ipratropium use. It primarily acts on the respiratory system, not the cardiovascular system.
C. Relieving nasal congestion is incorrect in this context, though ipratropium nasal spray can be used for rhinorrhea.
D. Reducing coughing is not the primary purpose. While bronchodilation may indirectly reduce cough by improving airflow, it is not a cough suppressant.
Correct Answer is C
Explanation
A. Deep vein thrombosis is not a known risk factor for obstructive sleep apnea. Sleep apnea is primarily related to airway obstruction rather than circulatory issues.
B. Being female is incorrect. Obstructive sleep apnea is more common in males than females, although postmenopausal women have an increased risk.
C. Obesity is correct. Excess weight, particularly around the neck, increases the risk of airway obstruction during sleep, making obesity a major risk factor for obstructive sleep apnea.
D. Atherosclerosis is not a direct risk factor. However, untreated obstructive sleep apnea can contribute to cardiovascular issues, including hypertension and atherosclerosis.
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