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. Headache is correct. Clients with obstructive sleep apnea often experience morning headaches due to intermittent hypoxia and hypercapnia caused by repeated episodes of airway obstruction during sleep.
B. Hypotension is incorrect. Obstructive sleep apnea is more commonly associated with hypertension rather than hypotension due to the body's stress response to low oxygen levels.
C. Constipation is not a common symptom of obstructive sleep apnea. Gastrointestinal symptoms are not typically associated with this condition.
D. Nausea is not a characteristic finding in obstructive sleep apnea. The primary symptoms involve respiratory and neurological effects due to oxygen deprivation during sleep.
Correct Answer is A
Explanation
A. Alcohol relaxes throat muscles, worsening obstructive sleep apnea (OSA). The client should be educated to avoid alcohol, even while using a CPAP machine.
B. CPAP improves sleep quality and reduces daytime sleepiness, making this statement accurate.
C. Weight loss can reduce the severity of OSA, and some clients may no longer need treatment after significant weight loss.
D. The CPAP machine functions by delivering continuous air pressure to keep the airway open, which is a correct statement.
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