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 D

Explanation

Choice A rationale

Airway obstruction is not a common complication of a femoral head fracture or skin traction.

Choice B rationale

Pneumonia can cause shortness of breath but is not the most likely complication in this scenario.

Choice C rationale

Pneumothorax is less likely in this context compared to a fat embolism.

Choice D rationale

Fat embolism is a known complication of fractures, especially long bone fractures like the femoral head. It can cause respiratory distress and dyspnea.

A. The area surrounding the insertion site feels warm to the touch. B. The infusion rate has stopped but the tubing is not kinked. C. There is fluid leaking around the insertion site. D. There is no blood return when the tubing is aspirated.

Correct Answer is A

Explanation

Choice A rationale

Warmth around the IV insertion site is a classic sign of phlebitis, which is inflammation of the vein. This can be caused by irritation from the IV catheter or the infusing solution.

Choice B rationale

A stopped infusion rate without a kinked tubing could indicate an occlusion or infiltration, but it is not a specific sign of phlebitis.

Choice C rationale

Fluid leaking around the insertion site suggests infiltration or extravasation, where the IV fluid leaks into the surrounding tissue, rather than phlebitis.

Choice D rationale

Lack of blood return when aspirating the tubing could indicate a positional issue or occlusion, but it is not specific to phlebitis.

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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

A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?

Correct Answer is D

Explanation

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

Correct Answer is A

Explanation

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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?