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. Crossing the legs can actually increase the risk of venous stasis and clot formation, which can lead to a pulmonary embolism. The client needs further teaching to avoid this habit.
B. Smoking increases the risk of blood clot formation, so quitting smoking is an appropriate preventive measure.
C. Staying hydrated helps maintain good blood flow and reduces the risk of clot formation.
D. Regular exercise and weight management help prevent venous stasis and clot formation, lowering the risk of pulmonary embolism.
Correct Answer is D
Explanation
A. Checking blood pressure is important but does not confirm a myocardial infarction. Hypotension or hypertension may be present, but they are not definitive diagnostic tools.
B. Auscultating heart tones can help assess for murmurs or extra sounds, but it cannot diagnose a myocardial infarction.
C. Radiating pain to the left arm is a classic symptom, but not all clients experience it, and its absence does not rule out an MI.
D. Performing a 12-lead ECG is the most important diagnostic tool for identifying myocardial infarction. It provides real-time evidence of ischemic changes, such as ST-segment elevation or depression, confirming or ruling out an MI.
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