Patient Data

The nurse reviews the client's assessment data and test results.

For each client finding, click to indicate if the data is consistent with heart failure, pulmonary embolism, or myocardial infarction. Each column must have at least one response option selected.

Weight gain

Cardiac laboratory results

Shortness of breath

Chest pain

Heart rate

Chest x-ray results

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,C"},"E":{"answers":"A,B,C"},"F":{"answers":"B"}}

Weight gain: Indicates fluid retention (peripheral edema, pleural effusion), which is characteristic of heart failure.
Cardiac laboratory results: Markedly elevated BNP (806 pg/mL) is strongly indicative of heart failure. Troponin is within normal limits, making MI less likely.
Shortness of breath: Can occur in all three conditions—heart failure (fluid overload), pulmonary embolism (impaired perfusion), and myocardial infarction (decreased cardiac output).
Chest pain: Can be seen in both pulmonary embolism (often pleuritic) and myocardial infarction (pressure/heaviness).
Heart rate: Tachycardia is a nonspecific finding and can occur in all three conditions due to stress, hypoxia, or decreased cardiac output.
Chest x-ray results: Pleural effusion is most consistent with heart failure due to fluid accumulation.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Ventricular arrhythmias warrant immediate intervention because they indicate a life-threatening cardiac complication. Clients with a history of bilateral adrenalectomy are at risk for adrenal crisis, which can cause electrolyte imbalances such as hyperkalemia. Hyperkalemia can precipitate ventricular arrhythmias, making this a critical, time-sensitive finding requiring urgent treatment.

B. Profound weight gain may indicate fluid retention, which is important to monitor but is not immediately life-threatening. It requires assessment and intervention over time but does not take priority over a potentially fatal arrhythmia.

C. Decreased urinary output is a sign of compromised renal perfusion or fluid imbalance. While concerning, it is not as immediately life-threatening as ventricular arrhythmias and typically follows assessment and stabilization of cardiovascular status.

D. Low blood glucose levels (hypoglycemia) are important to identify and treat promptly in clients without adrenal function, but the immediate threat to life from ventricular arrhythmias takes precedence. Hypoglycemia should be treated after ensuring cardiac stability.

A. Provide with only finger foods. B. Feed the client the entire meal. C. Orient the client to the location of the food on the plate. D. Ask family to visit during meal time to assist with feeding.

Correct Answer is C

Explanation

A. Providing only finger foods unnecessarily limits the client’s diet and independence. The client may be able to eat with utensils if properly guided, so restricting to finger foods is not required.

B. Feeding the client the entire meal removes the client’s autonomy and may not be necessary. Many clients with visual impairments can feed themselves with proper orientation and assistance.

C. Orienting the client to the location of food on the plate is the most appropriate intervention. Using techniques such as the “clock method,” where different foods are described in terms of clock positions, helps the client eat independently and safely despite visual impairment. This approach promotes autonomy and reduces the risk of spills or injury.

D. Asking family to assist during meal times may provide support, but it is not the primary strategy for fostering independence and safety. The UAP should first use structured orientation techniques to help the client feed themselves.

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Patient Data The nurse reviews the client's assessment data and test results. For each client finding, click to indicate if the data is consistent with heart failure, pulmonary embolism, or myocardial infarction. Each column must have at least one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

A client who was splashed with a chemical has both eyes covered with bandages. When assisting the client with eating, which intervention should the nurse instruct the unlicensed assistive personnel (UAP) to implement?

Correct Answer is C

Explanation

The nurse is performing an initial wound assessment on a client's pressure injury and notes severe tissue destruction inhibiting the wound edges to approximate. Which wound healing technique will likely be used?

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

Patient Data The client returns to the clinic for his four week follow up appointment. Which 3 statements made by the client indicate his depression is improving?

Patient Data The nurse has received initial prescriptions for the client and is planning nursing care. Select 2 outcomes that would be appropriate for the nurse to include for this client's plan of care.

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

A client who is experiencing a first gouty arthritis attack and reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800 mg by mouth as prescribed. Which instruction should the nurse include in the discharge teaching?

Patient Data

The nurse reviews the client's assessment data and test results.

For each client finding, click to indicate if the data is consistent with heart failure, pulmonary embolism, or myocardial infarction. Each column must have at least one response option selected.