A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take?

Reference Range:

High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

Explain that the client may need medication therapy.

Ask the client about hereditary cardiac risk factors.

Confirm that this value is helpful in reducing cardiac risk.

Encourage the client to reduce consumption of fatty foods.

Answer and Explanation

The Correct Answer is C

Rationale

A. This is not appropriate because a high HDL level (85 mg/dL) is beneficial and does not typically necessitate medication therapy solely for raising HDL.

B. This is reasonable to assess overall cardiovascular risk factors, including hereditary factors, which can influence the management and prevention of heart disease.

C. It reinforces the positive impact of a high HDL level on reducing cardiovascular risk and provides the client with valuable information about their health status.

D. While dietary advice is important, specifically targeting fatty foods may not be necessary if the client's HDL level is already high. General dietary recommendations for heart health are beneficial but should be tailored to individual needs.

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Correct Answer is A

Explanation

Rationale

A. The client's pH is low (acidotic), and the PaCO2 is high (respiratory acidosis). Increasing the rate of ventilation (respiratory rate) can help to decrease PaCO2 by increasing alveolar ventilation, thereby helping to correct respiratory acidosis.

B. Expiratory flow time affects the time available for exhalation. While this may affect the overall mechanics of ventilation, it is not directly targeting the primary issue of elevated PaCO2 and acidosis.

C. Increasing tidal volume increases the volume of air delivered with each breath. This can improve ventilation efficiency but may not address the underlying problem of elevated PaCO2 unless it leads to increased minute ventilation.

D. Expiratory pressure is related to positive end-expiratory pressure (PEEP), which helps maintain alveolar recruitment and improve oxygenation. Decreasing expiratory pressure may not directly address the elevated PaCO2 and acidosis.

A. Volume of pedal pulses. B. Length of capillary refill. C. Rhythm of apical pulse. D. Degree of skin elasticity.

Correct Answer is C

Explanation

Rationale

A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.

B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.

C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.

D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.

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A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take? Reference Range: High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Correct Answer is C

Explanation

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A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take?

Reference Range:

High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]