The nurse is analyzing the diagnostic test results of a patient who is in the emergency department for shortness of breath. Which diagnostic test result does the nurse anticipate to suggest the cause of the shortness of breath is from heart failure?

Echocardiogram results with an ejection fraction of 55%

BNP results of 155 pg/mL (reference range <100 pg/mL)

EKG results of sinus rhythm with occasional premature ventricular contractions (PVCS)

ABG result with a PaCO2 of 30 mmHg (reference range 35-45 mmHg)

Answer and Explanation

The Correct Answer is B

A. Echocardiogram results with an ejection fraction of 55%: An ejection fraction (EF) of 55% is within the normal range, indicating preserved systolic function. While some forms of heart failure, such as HFpEF (heart failure with preserved ejection fraction), can occur, a normal EF alone does not strongly suggest acute heart failure as the cause of shortness of breath.

B. BNP results of 155 pg/mL (reference range <100 pg/mL): Brain natriuretic peptide (BNP) is released in response to ventricular stretch and increased intracardiac pressures. A BNP of 155 pg/mL is elevated, supporting a cardiac etiology of dyspnea, such as acute or chronic heart failure. BNP is a sensitive and specific biomarker for distinguishing heart failure from other causes of shortness of breath.

C. EKG results of sinus rhythm with occasional premature ventricular contractions (PVCs): Sinus rhythm with occasional PVCs does not indicate heart failure. While arrhythmias may coexist with heart failure, this finding alone does not explain the patient’s dyspnea or support a heart failure diagnosis.

D. ABG result with a PaCO2 of 30 mmHg (reference range 35-45 mmHg): A low PaCO2 reflects hyperventilation, which may be a compensatory response to hypoxia or pulmonary pathology. While it provides information on respiratory status, it is nonspecific and does not directly indicate heart failure as the underlying cause of dyspnea.

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 A

Explanation

A. "It is getting more difficult to walk up the stairs.": Increasing fatigue and exertional dyspnea are classic early signs of heart failure, indicating that the heart is no longer able to meet the body’s oxygen demands during activity. Difficulty with activities of daily living, such as climbing stairs, reflects reduced cardiac output and the onset of symptomatic heart failure.

B. "I have noticed a loss of appetite recently.": Loss of appetite is a nonspecific symptom and may occur with many conditions, including gastrointestinal issues or medication side effects. While it can be seen in advanced heart failure due to congestion, it is not an early or specific indicator of developing heart failure in a post-MI patient.

C. "I have been constipated lately.": Constipation is not directly associated with heart failure; it is more often related to diet, medications (like opioids), or reduced physical activity. It does not provide significant information about cardiac function in this context.

D. "I have trouble remembering things recently.": Cognitive changes are nonspecific and can result from a variety of causes, including stress, medications, or metabolic disturbances. They are not an early or reliable indicator of developing heart failure following myocardial infarction.

A. Contact respiratory therapy to wean the client from the ventilator B. Discuss the need for a tracheostomy tube during interprofessional rounding C. Document the length of time the client has been intubated in the chart D. Notify the provider that the endotracheal tube must be replaced in one week

Correct Answer is B

Explanation

A. Contact respiratory therapy to wean the client from the ventilator: While respiratory therapy plays a key role in ventilator management, this patient has already failed a spontaneous breathing trial. Immediate weaning attempts are unlikely to succeed and could cause fatigue or respiratory compromise. The focus should shift to alternative long-term airway strategies.

B. Discuss the need for a tracheostomy tube during interprofessional rounding: Prolonged intubation (typically >10–14 days) increases the risk of laryngeal injury, ventilator-associated pneumonia, and patient discomfort. Discussing a tracheostomy allows the interprofessional team to evaluate the benefits of a more secure, long-term airway, improve patient comfort, and facilitate eventual weaning from the ventilator.

C. Document the length of time the client has been intubated in the chart: Documentation is important for tracking intubation duration but is not an intervention to address the failed weaning trial. Alone, it does not actively guide management or prevent complications from prolonged intubation.

D. Notify the provider that the endotracheal tube must be replaced in one week: Routine replacement of a functioning endotracheal tube is not indicated. The priority is evaluating long-term airway management options, such as tracheostomy, rather than scheduling elective tube replacement.

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

The nurse is analyzing the diagnostic test results of a patient who is in the emergency department for shortness of breath. Which diagnostic test result does the nurse anticipate to suggest the cause of the shortness of breath is from heart failure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient admitted to observation for a suspected myocardial infarction. What statement made by this patient would alert the nurse to suspect the development of heart failure?

Correct Answer is A

Explanation

The nurse is caring for a client on a ventilator who had an endotracheal tube placed 13 days ago and failed the spontaneous breathing trial today. What action should the nurse take to manage the patient's care?

Correct Answer is B

Explanation

The nurse is suctioning a patient's tracheostomy. Which assessment finding observed by the nurse during suctioning indicates that the procedure should be stopped immediately?

A nurse is caring for a patient with a diagnosis of myocardial infarction (MI), who reports chest pain 8/10. The nurse administers a sublingual nitroglycerin tablet as prescribed. After 5 minutes, the chest pain is 6/10. What action does the nurse take first?

The intensive care unit (ICU) nurse plans care for a patient with a hemodynamic monitoring system for central venous pressure (CVP). In the plan of care, which complications does the nurse monitor for? Select all that apply.

The nurse is preparing to suction the endotracheal tube (ETT) of a patient who is on a ventilator using a closed in-line system (see image below or in attachments). What action does the nurse take first?

The nurse is performing hourly rounds on a patient with a chest tube attached to a 3-chamber water seal drainage system. The nurse observes constant bubbling in the water seal chamber. What action should the nurse take first?

When entering the room of a patient who has a chest tube attached to a water-seal drainage system, the nurse observes the chest tube is lying on the floor. Which of the following actions should the nurse take first?