Mr. James, a 68-year-old man with a history of chronic heart failure (reduced ejection fraction), presents to the ED with increasing shortness of breath, fatigue, and a 4 kg weight gain over the past 3 days. He is alert but appears anxious and is using accessory muscles to breathe. Vital signs are:

BP: 150/90 mmHg

HR 112 bpm, irregular

RR: 28/min

Sp0, 89% on room air

Bibasilar crackles are noted on auscultation.

An IV line is in place, and telemetry shows atrial fibrillation.

Which of the following interventions should be prioritized to address the most immediate concern?

Educate the patient on fluid restriction and daily weights

Prepare the patient for synchronized cardioversion

Administer prescribed IV furosemide

Notify the physician of the new-onset atrial fibrillation

Answer and Explanation

The Correct Answer is C

A. While education on fluid restriction and daily weights is important for long-term management, it does not address the acute respiratory distress the patient is experiencing.
B. Synchronized cardioversion may be considered later for atrial fibrillation, but the immediate concern is respiratory compromise due to fluid overload, not arrhythmia alone.
C. Administering IV furosemide (a loop diuretic) is the priority intervention. The patient is showing signs of acute decompensated heart failure with pulmonary congestion (bibasilar crackles, dyspnea, oxygen saturation of 89%, weight gain). IV diuretics reduce preload and help relieve fluid overload, improving breathing and oxygenation.
D. Notifying the physician is appropriate, but not the first action. The nurse should act on existing orders (e.g., IV diuretics) to stabilize the patient’s condition before escalating.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. High Fowler's with neck in a neutral position — While a neutral neck position is correct to reduce tension on the suture line, high Fowler's may cause discomfort or strain after surgery.
B. Semi-Fowler's with neck extended — Neck extension is contraindicated as it can put strain on the surgical site and compromise healing.
C. High Fowler's with neck extended — Both the high Fowler’s position and neck extension are inappropriate postoperatively as they can increase tension on the incision and risk complications.
D. Semi-Fowler's with neck in a neutral position — This position reduces swelling and pressure on the neck area while minimizing tension on the surgical site, promoting healing and preventing complications such as hemorrhage or airway obstruction.

A. Potassium level B. Oxygen saturation C. Blood pressure and temperature 38.1 C 100.6F D. Breath sounds

Correct Answer is C

Explanation

A. The potassium level of 3.6 mEq/L is within the normal range (3.5–5.0 mEq/L) and does not require follow-up.
B. Oxygen saturation of 97% on room air is normal and does not indicate a concern.
C. Blood pressure of 168/70 mm Hg indicates systolic hypertension, and a temperature of 38.1°C (100.6°F) suggests a possible hypermetabolic state or impending thyroid storm in the setting of hyperthyroidism — this combination requires follow-up. These findings may indicate worsening hyperthyroidism or progression toward a life-threatening complication.
D. Clear and present bilateral breath sounds are normal and do not warrant follow-up.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is eight hr. postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?

Correct Answer is D

Explanation

A nurse in the emergency department is caring for a female client with hyperthyroidism. After reviewing the assessment findings, which of the following findings require follow-up? Exhibits

Correct Answer is C

Explanation

Which intervention is most important for the nurse to implement for the client diagnosed with renal calculi?

An adult client hospitalized with pyelonephritis has been consistently consuming 3 to 3.5 liters of oral fluids per day since admission. How should the nurse respond to this finding?

The nurse is performing a physical assessment and obtaining a health history of a client admitted with acute heart failure. Which is an expected assessment finding associated with the client's diagnosis?

A nurse is teaching about levothyroxine to a client who has primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?

A nurse reviews hypertension with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

A female client has been experiencing recurrent cystitis. What health education should the nurse provide to this client?

A client has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate reading, the nurse confirms that the client has performed which action?