The nurse is reviewing the laboratory values for the client diagnosed with heart failure and notes the sodium level is 128 mEq/L (normal 135-145mEq/L). How should the nurse interpret this finding?

There is an increased risk for cardiac dysrhythmias

There is dilutional hyponatremia and fluid retention

There is an imbalance in the sodium-potassium pump

The client is in acute renal failure related to heart failure

Answer and Explanation

The Correct Answer is B

A.   Increased risk for cardiac dysrhythmias: While hyponatremia can sometimes contribute to cardiac dysrhythmias, it's not the primary concern in this case. The main issue is fluid overload.
B.   Hyponatremia, or low sodium levels, is often associated with heart failure. In this condition, the heart's reduced pumping ability leads to fluid retention, which dilutes the sodium concentration in the blood.
C.   Imbalance in the sodium-potassium pump: While this can contribute to electrolyte imbalances, it's not the direct cause of hyponatremia in heart failure.
D.   Acute renal failure: While heart failure can lead to acute kidney injury, hyponatremia is primarily a result of fluid overload rather than kidney dysfunction.

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Correct Answer is ["A","C","D"]

Explanation

A. Increased respiratory rate - Fluid overload can lead to pulmonary edema, which causes difficulty breathing and an increased respiratory rate.
B. Increased temperature - Fluid overload does not typically cause a temperature increase. A fever may indicate infection rather than fluid overload.
C. Increased heart rate - The body compensates for fluid overload by increasing the heart rate to maintain cardiac output.
D. Increased blood pressure - Fluid overload leads to increased blood volume, which results in elevated blood pressure.
E. Increase hematocrit - Hematocrit usually decreases with fluid overload, as it is diluted by the extra fluid volume.

A. "How many pillows do you sleep on mister" B. "Do you have chest pain when you walk up the steps?" C. "Do you find that your rings and shoes feel tight at the end of the day?" D. "How many times do you get up to void at night?"

Correct Answer is A

Explanation

A. This question assesses the client's level of orthopnea, which is a condition where the client experiences difficulty breathing when lying flat. People with heart failure may need to use multiple pillows to prop themselves up to breathe more easily at night, making it an important question to assess respiratory status.
B. Chest pain with exertion can be indicative of cardiovascular issues but this question does not directly assess the client's respiratory status.
C. Tight rings and shoes can indicate fluid retention and edema, but it does not provide specific information about respiratory status.
D. Frequent nighttime voiding (nocturia) is common in heart failure, but it relates more to kidney function and fluid retention rather than respiratory function.

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The nurse is reviewing the laboratory values for the client diagnosed with heart failure and notes the sodium level is 128 mEq/L (normal 135-145mEq/L). How should the nurse interpret this finding?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

Correct Answer is A

Explanation

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