A nurse is admitting a new client to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?
Draw blood for lab studies
Weigh the client
Assess respiratory status
Insert a Foley catheter
The Correct Answer is C
Choice A reason: Drawing blood for lab studies, such as BNP or electrolytes, is important in heart failure to assess severity and guide treatment. However, 2+ pitting edema and left ventricular enlargement suggest acute pulmonary congestion, making respiratory assessment the priority to detect life-threatening complications like pulmonary edema.
Choice B reason: Weighing the client monitors fluid status in heart failure, as weight gain indicates fluid retention. While important, it is secondary to assessing respiratory status, as edema and ventricular enlargement suggest possible pulmonary edema, which poses an immediate threat to oxygenation.
Choice C reason: Left ventricular enlargement and 2+ pitting edema indicate left-sided heart failure, which can lead to pulmonary edema, causing dyspnea and hypoxia. Assessing respiratory status first ensures detection of crackles or respiratory distress, enabling prompt intervention to prevent respiratory failure or worsening heart failure.
Choice D reason: Inserting a Foley catheter monitors urine output in heart failure but is not the first action. Respiratory distress from pulmonary edema, suggested by edema and ventricular enlargement, is a more immediate concern, requiring assessment of breathing to ensure adequate oxygenation and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.44"]
Explanation
Step 1: Calculate the total units to be given per hour: 18 × 90 = 1620 units/hour Result = 1620 units/hour
Step 2: Determine the concentration of Heparin in 1 mL: 25000 ÷ 250 = 100 units/mL Result = 100 units/mL
Step 3: Calculate the required volume in mL/hr using total units per hour: (1620 ÷ 100) = 16.2 mL/hr Result = 16.2 mL/hr
Final answer 16.2 mL/hr
Question 47
Calculate the initial bolus of Heparin. Heparin is ordered as 80 units/kg. The client weighs 90 kg. How many mL would you administer using a vial of Heparin labeled Heparin 5000 units/mL?
The correct answer is 1.44 mL
Explanation:
Step 1: Calculate the total number of units required for the bolus: 80 × 90 = 7200 units Result = 7200 units
Step 2: Use the vial concentration to find out how many mL deliver 7200 units: (7200 ÷ 5000) = 1.44 mL Result = 1.44 mL
Final answer 1.44 mL
Correct Answer is D
Explanation
Choice A reason: Anorexia nervosa was described as a medical condition in the late 19th century by physicians like William Gull. It was recognized well before the 1960s, though diagnostic criteria were formalized later, making this statement false.
Choice B reason: Anorexia nervosa often leads to social isolation due to physical and psychological effects, not popularity. Thinness may be idealized, but the disorder’s behaviors (e.g., food restriction) and health decline typically impair peer relationships, making this false.
Choice C reason: Eating disorders, including anorexia nervosa, are a global health issue, not limited to the United States and Europe. They occur in various cultures, particularly where thinness is idealized, making this statement inaccurate and overly restrictive.
Choice D reason: Cultures emphasizing thinness as a beauty standard increase the risk of eating disorders like anorexia nervosa by promoting body dissatisfaction and extreme dieting behaviors. Social pressures amplify psychological vulnerabilities, contributing to higher incidence rates, making this statement true.
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