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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Correct Answer is A

Explanation

A. The primary concern in this scenario is urinary retention, which can lead to kidney dysfunction (indicated by elevated BUN and creatinine). The priority intervention is relieving the retention by inserting a Foley catheter, which will help restore normal urinary output and prevent further complications.

B. MRI is not an immediate priority when the client is at risk for kidney damage due to urinary retention.

C. While IV fluids may be necessary, the first priority is relieving the obstruction causing urinary retention.

D. Drawing blood is important for assessing the client's condition but is not as urgent as managing urinary retention.

A. Serum insulin levels B. Hemoglobin levels C. Hemoglobin A1C level D. Fingerstick fasting blood glucose level

Correct Answer is C

Explanation

A. Serum insulin levels reflects short-term insulin secretion but does not indicate long-term glucose control.

B. Hemoglobin levels relate to anemia, not glucose control.

C. Hemoglobin A1C level reflects the average blood glucose over the past 2-3 months, providing an excellent measure of long-term control.

D. Fingerstick fasting blood glucose level reflects glucose levels at the moment of testing, not long-term control.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

Correct Answer is A

Explanation

After starting the treatment for type 2 diabetes mellitus 6 months earlier, a client is in the office for a follow-up examination. The nurse will monitor which laboratory test to evaluate the clients adherence to the antidiabetic therapy over the past few months?

Correct Answer is C

Explanation

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

Which information about continuous bladder irrigation will the nurse teach to a client who is being admitted for a transurethral resection of the prostate (TURP)?

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure would the nurse expect the health care provider to order to make an accurate diagnosis?

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?

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

Which lab value would be most likely to cause the following dysrhythmia?

A client with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the client's ventilation?