A nurse is caring for a client admitted to the intensive care unit. Assessment findings are:

BP 160/90

HR 100

RR 27

Sp02 89%

Central Venous Pressure (CVP) 18 mmHg

Pulmonary Arterial Wedge Pressure (PAWP) 21 mmHg. Echocardiogram: Ejection Fraction 30%

BNP 1300 pg/mL

What is the nurse's priority action?

Increase IV fluid infusion per protocol.

Lower the head of the clients bed in Trendelenburg position

Document CVP and continue to monitor.

Administer IV diuretic medications.

Answer and Explanation

The Correct Answer is D

A. Increasing IV fluids would exacerbate the client's fluid overload and worsen heart failure symptoms.

B. Trendelenburg positioning is typically used for shock management, but this client’s fluid overload needs to be addressed first.

C. Monitoring is important but does not address the immediate need to manage fluid overload.

D. The client's elevated CVP, PAWP, and BNP levels indicate fluid overload and heart failure with reduced ejection fraction. The priority is to reduce fluid overload by administering IV diuretics, which will help reduce the pressure in the heart and lungs, improving oxygenation and decreasing the risk of pulmonary edema.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Chronic asymptomatic HIV infection refers to a phase with no opportunistic infections and higher CD4+ counts.

B. A CD4+ T cell count below 200 cells/μL is abnormal and diagnostic of AIDS, not within the normal range.

C. The acute HIV infection phase occurs shortly after exposure, characterized by flu-like symptoms and high viral load, not opportunistic infections.

D. The presence of Pneumocystis jiroveci pneumonia (an AIDS-defining illness) and a CD4+ T cell count below 200 cells/μL confirms a diagnosis of AIDS.

A. Blood glucose of 182 mg/dL B. History of high cholesterol C. Elevated liver enzymes D. History of peptic ulcers

Correct Answer is C

Explanation

A. Blood glucose elevation is a concern for statins, but it is not a primary reason for questioning the order.

B. A history of high cholesterol is common and would not trigger concern regarding lovastatin.

C. Lovastatin can cause liver toxicity, so elevated liver enzymes are a contraindication or cause for concern when prescribing this medication. The nurse should verify this before starting the medication.

D. A history of peptic ulcers is unrelated to the use of lovastatin and would not be a concern in this case.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

After reviewing the client's chart upon admission to the unit, the nurse consults the healthcare provider about a new order for lovastatin (Mevacor). What triggered the nurse's action?

Correct Answer is C

Explanation

After receiving change-of-shift report about the following four clients, which client should the nurse assess first?

A nurse is caring for four clients. Which one would the nurse see first?

The proton pump inhibitor Esomeprazole (Nexium) is prescribed for a client who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?

Which client should the nurse assign as a roommate for a client who has aplastic anemia?

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right- sided heart failure?

A client who is on the progressive care unit develops atrial flutter, rate 150 with dyspnea, shortness of breath and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first?

A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. The students blood pressure is 119/76 and denies any health issues. Which action by the nurse is most appropriate?