The nurse is reviewing the patient’s recent symptoms and lab results. Which of the following symptoms or findings suggest worsening heart failure? (Select all that apply)
Oxygen saturation of 92% on room air
Bilateral pulmonary congestion on chest x-ray
Recent 5-lb weight gain
BUN of 28 mg/dL
Potassium of 4.9 mEq/L
Correct Answer : B,C
Choice A reason: Oxygen saturation of 92% is low-normal (95-100%), not specific to worsening heart failure acutely. It may reflect chronic lung issues or mild hypoxia, but alone, it’s not a definitive sign of decompensation.
Choice B reason: Bilateral pulmonary congestion on x-ray shows fluid in alveoli from left heart failure, impairing gas exchange. It’s a classic sign of worsening, as rising pressure backs fluid into lungs, causing dyspnea.
Choice C reason: A 5-lb weight gain over days indicates fluid retention, a hallmark of worsening heart failure. It reflects sodium and water buildup from reduced cardiac output, directly correlating with symptom exacerbation.
Choice D reason: BUN of 28 mg/dL (normal 7-20 mg/dL) suggests mild renal stress, possibly from diuretics. It’s not specific to worsening heart failure without symptoms like dyspnea, as it may reflect dehydration instead.
Choice E reason: Potassium of 4.9 mEq/L is normal (3.5-5.0 mEq/L), not indicating worsening heart failure. It may rise with ACE inhibitors, but this value alone doesn’t signal acute decompensation or symptom progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Glucose of 122 mg/dL is mildly elevated, suggesting prediabetes, but not urgent in hypertension. It’s a chronic risk factor, less critical than renal function for immediate provider attention.
Choice B reason: Hemoglobin of 14.7 g/dL is normal (12-18 g/dL), requiring no action in hypertension. It reflects oxygen capacity, not directly tied to blood pressure or acute complications needing reporting.
Choice C reason: Potassium of 4.5 mEq/L is normal (3.5-5.0 mEq/L), not concerning in hypertension. It’s relevant with medications, but this value alone doesn’t warrant immediate communication to the provider.
Choice D reason: Creatinine of 2.8 mg/dL (normal 0.5-1.2 mg/dL) indicates renal impairment, critical in hypertension. It suggests kidney damage from pressure, needing urgent reporting to adjust treatment and prevent progression.
Correct Answer is A
Explanation
Choice A reason: Auscultating lung sounds post-albuterol assesses treatment efficacy in asthma exacerbation. Reduced wheezing or improved air entry indicates bronchodilation, guiding further care, making it the priority to evaluate respiratory response immediately.
Choice B reason: Measuring temperature monitors infection, a possible asthma trigger, but it’s not the priority post-treatment. Albuterol targets acute bronchospasm, so assessing respiratory effect trumps systemic checks like fever in this moment.
Choice C reason: Encouraging ambulation is premature post-albuterol; patients need rest during exacerbation. It risks worsening dyspnea before confirming treatment success, making it less urgent than evaluating lung response to the bronchodilator.
Choice D reason: Documentation is essential but secondary to patient assessment post-treatment. Auscultating lung sounds first ensures albuterol’s effect is evaluated, as clinical response guides care before recording in the record.
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