The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to:

prepare to place the client in a single room.

ask the client if they wish to speak to a spiritual advisor.

explore the possibility of suicidal thoughts with the client.

explain to the client that they will not die for a long time.

Answer and Explanation

The Correct Answer is C

A.   While privacy may be important for a patient who is emotionally distressed, the priority is addressing
the client’s emotional state, not the physical environment.
B.   This might be helpful later, but the priority is to explore the patient's feelings and concerns regarding their condition first. Immediate emotional support is more important at this stage.
C.   When a patient expresses feelings of hopelessness, as in this case, the nurse must assess for potential suicidal ideation. This is a priority to ensure patient safety and to provide necessary psychological support or intervention.
D.   While reassurance is important, providing false or unrealistic expectations can lead to further disappointment. The nurse should focus on addressing emotional distress and offering realistic support rather than giving definitive assurances.

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Free Nursing Study Resources

Correct Answer is ["13.8"]

Explanation

The patient weighs 121 lbs, which is approximately 55 kg (121 ÷ 2.2).

The prescribed dose is 1 mg/kg, so the patient requires 55 mg of furosemide. The medication is supplied at a concentration of 40 mg per 10 mL.

To find out how many mL of furosemide to administer, set up a proportion: 40 mg is to 10 mL as 55 mg is to X mL.

Therefore, the nurse should administer 13.8 mL of furosemide, rounding to the nearest tenth.

A. The pacemaker is pacing abnormally B. Biventricular, pacing in both ventricles C. Atrial paced rhythm D. Atrial and ventricular pacing

Correct Answer is D

Explanation

A. This would be concerning, but it is not the correct choice. If a pacemaker is functioning abnormally, it would require an assessment and troubleshooting, not simply a routine rhythm.
B. This is typical for biventricular pacemakers used in heart failure patients, but it would not apply to a patient with a standard pacemaker unless specified. A recent pacemaker placement does not necessarily indicate biventricular pacing.
C. This is correct if only the atrium is paced; however, in the case of a typical pacemaker like DDD (dual- chamber pacemaker), both the atrium and ventricle are paced.
D. This is correct for dual-chamber pacemakers (like DDD), which pace both the atrium and the ventricle to coordinate the heart's rhythm.

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The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to:

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Naxlex Comprehensive Predictor Exams

A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 Ibs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

Correct Answer is ["13.8"]

Explanation

The nurse is assessing the client with a recent pacemaker placement. The client's monitor is displaying what type of rhythm?

Correct Answer is 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?

The nurse would assess the client diagnosed with disseminated intravascular coagulation (DIC) for which manifestation of the disorder?

Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

Complete the following sentences with the list of drop down The nurse assesses the client's rhythm on the monitor. The patient is unresponsive with no pulse. The nurse identifies the rhythm asdropdown. The nurse's priority action isdropdown

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Which behavior observed by the nurse causes a suspicion that a depressed client may be suicidal?

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