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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Schedule an appointment for a prostate-specific antigen (PSA) test. PSA screening is typically considered for men aged 50 and older, or earlier for those with higher risk factors like family history. Since the client does not mention any risk factors, this option is not a priority.

B. Schedule his next appointment for 1 year from now. While it is standard for clients without significant health issues to have annual exams, the nurse should prioritize education on risk factors related to hypertension, given the client's slightly elevated blood pressure.

C. Provide information about how to reduce risk factors of hypertension. Even though the client's blood pressure is in the elevated category, it is important to educate him about how to reduce the risk of developing hypertension, particularly since he is African-American, which is a population at higher risk for hypertension.

D. Provide information for a weight loss plan that includes increasing physical activity. The client has a normal BMI of 24, so weight loss would not be necessary. However, regular physical activity is important for overall cardiovascular health.

A. Smoking B. Obesity C. Genetic predisposition D. Hypertension E. Hypercholesterolemia

Correct Answer is ["A","B","D","E"]

Explanation

A. Smoking: Smoking is a major modifiable risk factor for atherosclerosis. Cessation can significantly reduce the risk of disease progression.

B. Obesity: Obesity is a modifiable risk factor. Weight loss through diet and exercise can help lower the risk of atherosclerosis.

C. Genetic predisposition: Genetic predisposition is a non-modifiable risk factor. It cannot be changed or controlled, so it is not considered a modifiable factor.

D. Hypertension: Hypertension is a modifiable risk factor, as it can be managed through lifestyle changes and medication.

E. Hypercholesterolemia: Hypercholesterolemia (high cholesterol levels) is a modifiable risk factor because it can be controlled through diet, exercise, and medication.

View Question and Answer

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

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

A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg. his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

The nurse notes the patient’s lower legs are brown and discolored and their feet are cold and slightly blue in color when in the dependent position. Which of the following actions should the nurse take?

A nurse is assisting with the plan of care for a client immediately following a cardiac catheterization with coronary angiography. An arterial closure device was used to close the access site. Which of the following interventions should the nurse recommend?

A nurse is reinforcing instructions with a client who is scheduled for a cardiac catheterization with angiography. Which of the following statements should the nurse include in the instructions?

A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include? (Select all that apply.)

A nurse is reinforcing teaching about a heart healthy diet with a group of clients who have hypertension. Which of the following statements by the clients indicates a need for further teaching?

A nurse is preparing to administer digoxin 0.25 mg PO to a client. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer to the client? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

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.