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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. "I can eat frozen juice bars for a snack." B. "I can have a cola drink twice a day." C. "I will replace table salt with dried herbs." D. "Fresh fruits are good to include with meals."

Correct Answer is B

Explanation

A. "I can eat frozen juice bars for a snack." Frozen juice bars are generally low in sodium and are a healthy snack option for clients with hypertension. This choice is acceptable as long as they are made from 100% juice and do not contain added sugars or sodium.

B. "I can have a cola drink twice a day." Cola drinks contain caffeine, sugar, and sometimes sodium, which can increase blood pressure. Clients with hypertension should limit their intake of sugary or caffeinated drinks. This statement indicates a need for further teaching.

C. "I will replace table salt with dried herbs." Replacing table salt with dried herbs is a good practice to reduce sodium intake, which can help manage hypertension. This statement does not indicate a need for further teaching.

D. "Fresh fruits are good to include with meals." Fresh fruits are low in sodium and rich in potassium, which can help regulate blood pressure. This is a good dietary choice for clients with hypertension and does not indicate a need for further teaching.

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 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?

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

A nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is reinforcing teaching with a client who has hypertension and is taking propranolol. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assisting with care of a client who has a prescription for 3.000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)

A nurse is administering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?

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.

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

A nurse is monitoring a client's peripheral circulation. Identify where the nurse should palpate to check the posterior tibial pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

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.