A nurse is assisting with the admission of a client who has a history of heart failure.

Exhibits

Which of the following findings require immediate follow-up by the nurse? Select all that apply.

Neurological assessment

Vital signs

Basic Metabolic Profile (BMP) laboratory report

Cardiac enzymes laboratory report

B-natriuretic peptide (BNP) laboratory report

Respiratory assessment

Answer and Explanation

Correct Answer : B,D,E,F,G

A. Neurological assessment: The neurological assessment indicates the client is alert and oriented, which is good; however, it does not require immediate follow-up.

B. Vital signs: The vital signs indicate an elevated heart rate (138/min), elevated respiratory rate (28/min), and borderline low blood pressure (96/75 mm Hg). These findings suggest potential hemodynamic instability and require immediate attention to assess the underlying cause and determine the appropriate interventions.

C. Basic Metabolic Profile (BMP) laboratory report: The BMP is largely within normal limits except for the glucose level (148 mg/dL), which is slightly elevated but not critically so. There is no urgent need for follow-up based on the BMP findings unless other symptoms arise.

D. Cardiac enzymes laboratory report: The troponin level is elevated (10.1 ng/mL), indicating myocardial injury, which requires immediate follow-up to assess the risk of acute coronary syndrome or worsening heart failure. This is a critical finding that warrants further evaluation.

E. B-natriuretic peptide (BNP) laboratory report: The BNP level is significantly elevated at 800 ng/mL, indicating worsening heart failure. This finding requires immediate follow-up to assess the client's condition and determine appropriate management strategies.

F. Respiratory assessment: The respiratory assessment shows an elevated respiratory rate (28/min) and oxygen saturation at 93% on supplemental oxygen. The presence of pink-tinged sputum may indicate pulmonary congestion or possible pulmonary edema, necessitating immediate follow-up.

G. ECG report: The ECG shows atrial fibrillation with a rapid ventricular response (RVR) at a rate of 135/min. This irregular heart rate can lead to decreased cardiac output and increased risk of thromboembolic events, requiring immediate follow-up to manage the heart rate and rhythm appropriately.

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Correct Answer is A

Explanation

A. Check the client's distal pulses in both legs. It is important to assess distal pulses to ensure adequate circulation and to detect any signs of potential complications, such as arterial occlusion or hematoma formation, after cardiac catheterization.

B. Keep the client overnight. Most clients do not need to be kept overnight after cardiac catheterization unless there are complications. This option is unnecessary in routine cases.

C. Restrict the client's oral fluids. Clients are encouraged to increase oral fluids after the procedure to help flush out the contrast dye used during the catheterization and reduce the risk of kidney damage.

D. Keep the client on bed rest for 12 hr. Bed rest is required for a few hours (typically 4-6 hours) after cardiac catheterization to reduce the risk of bleeding from the puncture site. However, 12 hours of bed rest is generally not necessary unless there are specific complications.

A. "You should expect to feel some tingling in the affected limb the day following the procedure." B. "You might be asked to perform mild exercises during the procedure." C. "You should not eat or drink for 4 hr following the procedure." D. "You might have to lie in bed for 6 hr after the procedure."

Correct Answer is D

Explanation

A. "You should expect to feel some tingling in the affected limb the day following the procedure." Tingling in the limb could indicate nerve or circulatory problems and should be reported immediately. It is not a normal post-procedure expectation.

B. "You might be asked to perform mild exercises during the procedure." Clients are typically instructed to remain still during a cardiac catheterization to avoid complications at the insertion site. Mild exercises are not a part of the procedure.

C. "You should not eat or drink for 4 hr following the procedure." NPO (nothing by mouth) status is usually required before the procedure, not after. Clients are encouraged to drink fluids after the procedure to help flush the contrast dye from their system.

D. "You might have to lie in bed for 6 hr after the procedure." After a cardiac catheterization, especially with a femoral artery approach, clients may be required to remain on bed rest for 4-6 hours to prevent bleeding or complications at the catheter insertion site.

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A nurse is assisting with the admission of a client who has a history of heart failure. Exhibits Which of the following findings require immediate follow-up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse is assisting with the admission of a client who has a history of heart failure.

Exhibits

Which of the following findings require immediate follow-up by the nurse? Select all that apply.