A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation.
Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

Irregular pulse.

Persistent fatigue.

Dependent edema.

Slurred speech.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Irregular pulse. While an irregular pulse is a common finding in atrial fibrillation, it is not the most critical finding to report immediately unless it is associated with other symptoms.

Choice B rationale

Persistent fatigue. Persistent fatigue is a common symptom in heart failure and atrial fibrillation but does not require immediate reporting unless it worsens significantly.

Choice C rationale

Dependent edema. Dependent edema is a common symptom in heart failure but does not require immediate reporting unless it is severe or worsening rapidly.

Choice D rationale

Slurred speech. This finding is critical to report immediately as it may indicate a stroke or transient ischemic attack (TIA) due to an embolus from atrial fibrillation. Prompt intervention is necessary to prevent further complications. .

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

Explanation

Wound infection is a significant risk factor for dehiscence. Infections can weaken the wound edges and delay healing, increasing the likelihood of the wound reopening.

Choice B rationale

Obesity is a risk factor for dehiscence because excess adipose tissue can place additional stress on the wound, impair blood flow, and delay healing.

Choice C rationale

Altered mental status is not directly associated with an increased risk of dehiscence. While it may affect a patient’s ability to follow postoperative care instructions, it is not a primary risk factor.

Choice D rationale

Pain medication administration is not a risk factor for dehiscence. Pain management is essential for recovery and does not contribute to wound reopening.

Choice E rationale

Poor nutritional state is a risk factor for dehiscence because adequate nutrition is essential for wound healing. Malnutrition can impair the body’s ability to repair tissues and increase the risk of wound complications.

A. Hypervolemia. B. Hyperkalemia. C. Low hemoglobin. D. Metabolic alkalosis.

Correct Answer is B

Explanation

Choice A rationale

Hypervolemia is not typically associated with extensive burn injuries. Burn patients often experience hypovolemia due to fluid loss from the burn wounds.

Choice B rationale

Hyperkalemia is a common finding in patients with extensive burn injuries. The destruction of cells releases potassium into the bloodstream, leading to elevated potassium levels.

Choice C rationale

Low hemoglobin is not a typical finding in the initial phase of burn injury. Hemoglobin levels may decrease later due to blood loss or hemodilution.

Choice D rationale

Metabolic alkalosis is not commonly associated with extensive burn injuries. Burn patients are more likely to experience metabolic acidosis due to tissue hypoxia and lactic acid accumulation.

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A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation.
Which of the following findings should the nurse plan to monitor for and report to the provider immediately?