A nurse is assessing a newly admitted client with a history of chronic heart failure who has new onset confusion after forgetting to take his medications for a few days. The client has peripheral edema, mild shortness of breath, and bilateral crackles in the lung bases. Which of the following assessments is the priority for the nurse?
Capillary refill and depth of peripheral edema
Abdominal sounds and obtain a BNP level
Neurological status and obtain electrolyte levels
Skin turgor and measure intake & output (I&O)
The Correct Answer is C
A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Serum potassium 3.2 mEq/L: A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates hypokalemia, which can cause serious cardiac arrhythmias and muscle weakness. This condition requires prompt correction and collaboration with the healthcare provider before surgery to avoid intraoperative and postoperative complications.
B. Pulse rate 65 bpm: A pulse rate of 65 bpm is within the normal range (60-100 bpm). While it should be monitored, it does not require immediate intervention or collaboration with the healthcare provider before surgery.
C. Hematocrit 36%: A hematocrit level of 36% is within the lower end of the normal range (35-45% for women). This does not indicate an immediate concern that requires prompt collaboration with the healthcare provider.
D. Blood pressure 144/82 mmHg: Although this blood pressure reading is slightly elevated, it is not uncommon and can be managed perioperatively. It does not require immediate intervention before surgery.
Correct Answer is C
Explanation
A. Client's serum pH is 7.41: This is within the normal range for blood pH (7.35-7.45) and does not specifically indicate a potassium deficit.
B. Client has a stage 2 sacral wound: This is related to skin integrity and does not directly impact potassium levels.
C. Client requires continuous nasogastric suction: Continuous nasogastric suction can lead to the loss of potassium as it removes gastric contents, which may include electrolytes.
D. Client has a history of adrenal insufficiency: While adrenal insufficiency can affect electrolyte balance, continuous nasogastric suction is a more immediate risk for potassium deficit.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
