The emergency room nurse is assessing a client with jugular venous distention, ascites, shortness of breath, and a 3-pound weight gain in the past 24 hours. Which of the following would the nurse anticipate being ordered?
Pulmonary Function Test
Alpha-1 Antitrypsin
Brain Natriuretic Peptide
Doppler Ultrasound
The Correct Answer is C
A. A pulmonary function test is used to assess lung diseases like COPD or asthma. It is not the primary diagnostic test for fluid overload and heart failure.
B. Alpha-1 antitrypsin deficiency is associated with early-onset COPD, but it does not relate to symptoms of fluid retention and heart failure as described in the question.
C. Brain Natriuretic Peptide (BNP) is correct. BNP is released when the ventricles stretch due to fluid overload, making it a key diagnostic marker for heart failure. Elevated BNP levels indicate increased cardiac filling pressures and volume overload, which match the client’s symptoms.
D. A Doppler ultrasound is useful for detecting deep vein thrombosis (DVT) or vascular issues, but it does not assess systemic fluid retention and heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Warfarin is commonly prescribed for long-term anticoagulation to prevent future clot formation. This statement is correct and does not require further teaching.
B. A Heparin infusion does not dissolve existing clots but prevents them from enlarging and new clots from forming, making this statement accurate.
C. The purpose of the Inferior Vena Cava (IVC) filter is to trap emboli from deep vein thrombosis (DVT) before they reach the lungs, not to prevent DVT formation. This statement is incorrect and requires further teaching.
D. An embolectomy is a surgical procedure to remove a pulmonary embolism, making this statement correct.
Correct Answer is B
Explanation
A. Taking 4 tablets over 20 minutes exceeds the recommended limit of 3 doses in 15 minutes and can dangerously delay emergency care if the pain is due to a heart attack.
B. The correct teaching is to take 1 sublingual nitroglycerin tablet at the onset of angina and, if pain persists after 5 minutes, activate emergency services while taking up to 2 additional tablets at 5-minute intervals. This ensures rapid symptom relief while promptly initiating emergency care if the angina does not resolve.
C. Calling 911 before taking any nitroglycerin delays immediate treatment of angina. Sublingual nitroglycerin is meant to relieve pain quickly, so contacting emergency services comes after assessing response to the first dose.
D. Waiting until all 3 tablets are taken before calling 911 can dangerously delay care if the angina is progressing to myocardial infarction. Early activation after the first dose ensures patient safety and timely intervention.
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