At midnight, an older male client with heart failure who is receiving 02 at 4 L/minute suddenly awakens with dyspnea. The nurse determines that he has audible rhonchi, tachycardia, and is cold and clammy. Which action should the nurse implement first?

Encourage deep breathing and coughing.

Provide emotional support to alleviate anxiety.

Insert an indwelling urinary catheter.

Place the client in high-Fowler's position.

Answer and Explanation

The Correct Answer is D

A. Encourage deep breathing and coughing: While deep breathing can help mobilize secretions, this client is in acute respiratory distress and likely experiencing pulmonary edema. He may be too compromised to perform these exercises effectively until his breathing is stabilized.

B. Provide emotional support to alleviate anxiety: Emotional support is important but not priority when physical symptoms such as dyspnea, tachycardia, and cold, clammy skin signal acute decompensation. Physiologic stabilization must occur before psychological needs.

C. Insert an indwelling urinary catheter: Monitoring fluid output is relevant in managing heart failure, but inserting a catheter does not address the client's immediate respiratory distress. This intervention can be performed after the client's breathing is supported.

D. Place the client in high-Fowler’s position: High-Fowler’s position improves lung expansion and decreases preload by promoting venous pooling in the lower extremities, thus reducing pulmonary congestion. It is the most immediate and effective non-invasive intervention for relieving acute dyspnea.

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Correct Answer is C

Explanation

A. Headache with sudden onset: While a sudden headache can be concerning and suggest a neurologic issue, it is not the most immediate sign of hemodynamic instability in the context of atrial fibrillation with hypotension. The priority is assessing cerebral perfusion.

B. Flat jugular vein distention (JVD) at 45 degrees: Flat JVD may reflect low central venous pressure, which is consistent with hypotension but is not as critical as changes in neurologic status. It is a supportive finding rather than a primary indicator to report.

C. Abnormal level of consciousness: Altered mental status indicates reduced cerebral perfusion due to a dangerously low cardiac output from rapid atrial fibrillation and hypotension. This is a critical, life-threatening sign that demands immediate medical intervention to restore adequate perfusion.

D. Nausea with vomiting: These symptoms can occur with hypotension or sympathetic stimulation but are nonspecific and less urgent compared to neurologic compromise. They do not require the same immediate action as a change in consciousness.

A. Respiratory rate of 22 breaths/minute. B. Production of frothy, pink-tinged secretions. C. Pitting edema of the ankles bilaterally. D. Irregular apical heart rhythm.

Correct Answer is B

Explanation

A. Respiratory rate of 22 breaths/minute: This rate is mildly elevated and may reflect exertional dyspnea or anxiety, but it does not indicate immediate respiratory distress. It requires monitoring but does not demand urgent intervention.

B. Production of frothy, pink-tinged secretions: This finding is a hallmark of acute pulmonary edema and signals severe left-sided heart failure with fluid backing up into the alveoli. It compromises oxygenation and requires urgent intervention, such as diuretics and supplemental oxygen.

C. Pitting edema of the ankles bilaterally: Pitting edema reflects chronic volume overload, often associated with right-sided heart failure. While concerning, it develops over time and is not as immediately life-threatening as pulmonary congestion with compromised gas exchange.

D. Irregular apical heart rhythm: An irregular rhythm is consistent with atrial fibrillation and explains the palpitations, but it is a known condition in this case. Unless accompanied by hemodynamic instability, it does not demand immediate intervention on its own.

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At midnight, an older male client with heart failure who is receiving 02 at 4 L/minute suddenly awakens with dyspnea. The nurse determines that he has audible rhonchi, tachycardia, and is cold and clammy. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

An adult male is admitted with dyspnea on exertion, persistent cough, and palpitations. His telemetry reveals atrial fibrillation. Which additional assessment finding warrants the most immediate intervention by the nurse?

Correct Answer is B

Explanation

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