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. Delivering a continuous flow of air pressure to keep the airway open is correct. CPAP (Continuous Positive Airway Pressure) prevents airway collapse during sleep, allowing for uninterrupted breathing and oxygenation.
B. Reducing daytime sleepiness is a benefit of CPAP use, but it is not its primary purpose—it is a secondary effect of improved oxygenation and sleep continuity.
C. Improving sleep quality also occurs with CPAP therapy, but this is an outcome rather than the primary purpose.
D. Promoting weight loss is not the function of CPAP therapy, though weight loss can help reduce OSA severity.
Correct Answer is D
Explanation
A. Heart failure is associated with central sleep apnea, not obstructive sleep apnea (OSA), which results from airway obstruction.
B. Opioid overdose is linked to central sleep apnea, where the brain fails to send proper signals to the breathing muscles. It does not cause obstruction of the airway.
C. Brainstem injury can affect respiratory drive, but it is not a direct cause of OSA, which is due to mechanical airway obstruction.
D. Enlarged tonsils are correct. In children and adults, enlarged tonsils can block the airway, making them a common cause of OSA.
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