Directions: Identify the nursing goals/outcome measures for this patient’s heart failure. (Select all that apply)

Decreased dyspnea and orthopnea

HgA1C less than 7

Reduction in peripheral edema

Stabilized or decreased BNP level

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: Decreased dyspnea and orthopnea reflect improved lung fluid clearance in heart failure. These symptoms lessen with reduced preload and better cardiac output, key goals indicating effective management and patient comfort.

Choice B reason: HgA1C <7 targets diabetes, not heart failure directly. While glycemic control benefits vasculature, it’s not a primary outcome measure for heart failure, which focuses on fluid and pump function instead.

Choice C reason: Reduced peripheral edema shows less fluid retention, a heart failure goal. It results from improved cardiac output and diuresis, alleviating discomfort and signaling successful treatment of volume overload.

Choice D reason: Stabilized or decreased BNP (<100 pg/mL ideally) indicates lower cardiac stress in heart failure. This biomarker drops with reduced wall tension, reflecting effective therapy and a key outcome measure.

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Correct Answer is B

Explanation

Choice A reason: Pneumonia causes cough, chest pain, and dyspnea, not facial pain or nasal drainage primarily. Fever fits, but symptom location (lungs vs. sinuses) rules it out for these presenting complaints.

Choice B reason: Acute sinusitis matches pain over nose/eyes/forehead, purulent drainage, fever, and malaise. Bacterial or viral inflammation of sinuses causes these classic signs, aligning perfectly with the patient’s symptoms.

Choice C reason: Tuberculosis involves chronic cough, weight loss, and night sweats, not acute facial pain or drainage. It’s a lung infection, lacking sinus-specific symptoms, making it an unlikely diagnosis here.

Choice D reason: Pharyngitis causes throat pain, not sinus-area pain or nasal drainage. Fever and malaise fit, but the location and purulence point to sinusitis, not a pharyngeal infection, in this case.

A. Metabolic alkalosis with hypoxemia B. Respiratory alkalosis with hypoxemia C. Metabolic acidosis with hypoxemia D. Respiratory acidosis with hypoxemia

Correct Answer is B

Explanation

Choice A reason: Metabolic alkalosis shows pH >7.45 with HCO3- >26 mEq/L from base excess. Here, pH is 7.48, but HCO3- is normal at 24 mEq/L, ruling out metabolic cause. PaO2 of 55 mmHg indicates hypoxemia, but the primary issue isn’t metabolic.

Choice B reason: Respiratory alkalosis occurs with pH >7.45 and PaCO2 <35 mmHg from hyperventilation. Here, pH is 7.48, PaCO2 is 28 mmHg, and HCO3- is normal, confirming respiratory etiology. PaO2 of 55 mmHg shows hypoxemia, matching this acute ventilatory pattern.

Choice C reason: Metabolic acidosis has pH <7.35 and HCO3- <22 mEq/L from acid gain. Here, pH is 7.48 and HCO3- is 24 mEq/L, contradicting acidosis. PaO2 of 55 mmHg indicates hypoxemia, but the acid-base status is alkalotic, not acidic.

Choice D reason: Respiratory acidosis features pH <7.35 and PaCO2 >45 mmHg from CO2 retention. Here, pH is 7.48 and PaCO2 is 28 mmHg, showing CO2 loss, not retention. Hypoxemia (PaO2 55 mmHg) is present, but the pattern is alkalotic.

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Directions: Identify the nursing goals/outcome measures for this patient’s heart failure. (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient comes to the doctor’s office with the following complaints: Moderate to severe pain over the nose, eyes, and forehead, purulent nasal drainage, fever, and malaise. The nurse suspects the patient is suffering from ___________.

Correct Answer is B

Explanation

Interpret the ABG results: pH: 7.48, PaCO2: 28 mmHg, PaO2: 55 mmHg, HCO3-: 24 mEq/L, SaO2: 87%

Correct Answer is B

Explanation

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Directions: Identify the nursing goals/outcome measures for this patient’s heart failure. (Select all that apply)

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