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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.
Choice B rationale
Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.
Choice C rationale
Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.
Choice D rationale
Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious complications.
Correct Answer is D
Explanation
Choice A rationale
The ropes being in the center of the wheel grooves is correct and ensures proper traction.
Choice B rationale
The ropes being securely attached to the pins is correct and necessary for effective traction.
Choice C rationale
The weights being equal on each side is correct and ensures balanced traction.
Choice D rationale
The weights resting against the foot of the bed is incorrect and can interfere with the effectiveness of the traction. .
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