The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

Crackles in bilateral lower lobes.

Heart rate of 92 beats/minute.

Blood pressure of 138/86 mm Hg.

Peripheral edema 1+ in ankles.

Answer and Explanation

The Correct Answer is A

Choice A reason: Crackles in bilateral lower lobes indicate pulmonary edema in heart failure, where reduced cardiac output causes fluid backup into alveoli, impairing gas exchange and causing dyspnea. This life-threatening emergency requires immediate diuretics or oxygen to reduce preload, preventing respiratory failure or hypoxia, prioritizing intervention.

Choice B reason: A heart rate of 92 beats/minute is normal and not urgent in heart failure, where dyspnea and fatigue suggest fluid overload. Crackles indicate pulmonary edema, a critical issue compromising oxygenation, necessitating immediate action to restore respiratory function, making heart rate less concerning.

Choice C reason: Blood pressure of 138/86 mm Hg is mildly elevated but not critical in heart failure. Crackles signal pulmonary edema, where fluid in alveoli impairs gas exchange, risking hypoxia. This requires urgent intervention like furosemide, as respiratory compromise is more immediate than managing stable blood pressure.

Choice D reason: Peripheral edema 1+ indicates fluid retention in heart failure but is less urgent than crackles, which signify pulmonary edema. Alveolar fluid causes dyspnea and hypoxia, requiring immediate diuretics. Edema is chronic, making respiratory assessment and intervention the priority to prevent acute respiratory failure.

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Correct Answer is A

Explanation

Choice A reason: Smoking exacerbates PAD via nicotine-induced vasoconstriction and endothelial damage, reducing blood flow and worsening atherosclerosis, especially post-MI. Cessation is critical to halt vascular damage, improve endothelial function, and prevent further MI or limb ischemia, addressing the primary pathophysiological driver of disease progression in this high-risk client.

Choice B reason: Reducing saturated fats and salt lowers LDL cholesterol and blood pressure, mitigating atherosclerosis in PAD and MI. However, smoking directly causes vasoconstriction and plaque progression, making cessation more urgent. Dietary changes are secondary, as nicotine’s immediate vascular effects pose a greater risk to perfusion and cardiovascular health.

Choice C reason: Trimming toenails short prevents injury in PAD, where poor perfusion impairs healing. However, smoking cessation is more critical, as nicotine’s vasoconstrictive effects directly reduce arterial flow, worsening ischemia. Nail care is a minor preventive measure compared to addressing smoking, the primary contributor to PAD’s pathophysiology.

Choice D reason: Applying a heating pad is contraindicated in PAD, as reduced sensation increases burn risk, and heat doesn’t improve arterial insufficiency. Smoking cessation is paramount, as nicotine exacerbates vasoconstriction, reducing blood flow and risking tissue necrosis. Cessation directly addresses PAD’s vascular pathology, making it the priority instruction.

A. “I just feel like my life is filled with emptiness.” B. “My panic attacks happen once every month.” C. “I have three firearms locked in a safe at home.” D. “My daughter is the only reason I keep trying.”

Correct Answer is C

Explanation

Choice A reason: Feeling emptiness reflects depression but is less urgent than access to firearms in suicidal ideation. Firearms indicate immediate risk, requiring safety planning. Emptiness needs therapy but not priority documentation, per suicide risk assessment and mental health nursing protocols.

Choice B reason: Monthly panic attacks are relevant but not the highest priority in suicidal ideation. Firearm access poses an immediate lethal risk, requiring urgent documentation. Panic attacks are secondary, per suicide risk assessment and psychiatric nursing care standards.

Choice C reason: Documenting firearm access is critical, as it indicates a means for suicide in a client with suicidal ideation. This prompts immediate safety interventions, like removing access, to prevent harm, per suicide risk assessment and patient safety protocols in psychiatric nursing.

Choice D reason: The daughter as a reason to live is protective but less urgent than firearm access, which poses immediate risk. Firearms require priority documentation to ensure safety. This is secondary, per suicide prevention and mental health assessment standards in nursing.

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The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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