Which client should the telemetry nurse assess first after receiving the a.m. shift report?

The client diagnosed with mitral valve stenosis who has heart palpitations.

The client diagnosed with arterial occlusive disease who has intermittent claudication.

The client diagnosed with deep vein thrombosis who has an edematous right calf.

The client diagnosed with heart failure who has pink frothy sputum.

Answer and Explanation

The Correct Answer is D

Choice A reason: The client with mitral valve stenosis experiencing heart palpitations is at risk of complications such as atrial fibrillation, which can lead to embolic events. While this is a serious condition that needs attention, it is not as immediately life-threatening as the presence of pink frothy sputum in a heart failure patient.

Choice B reason: The client with arterial occlusive disease and intermittent claudication is experiencing pain due to reduced blood flow to the extremities during activity. Although this condition requires management to prevent worsening ischemia, it is not as critical as the presentation of pink frothy sputum in a heart failure patient.

Choice C reason: The client with deep vein thrombosis (DVT) and an edematous right calf is at risk of developing a pulmonary embolism, which is a serious condition. However, the immediate symptoms do not suggest a current life-threatening emergency compared to the client with heart failure and pink frothy sputum.

Choice D reason: The client with heart failure who has pink frothy sputum must be assessed first. Pink frothy sputum is a sign of pulmonary edema, indicating severe left-sided heart failure. This condition is a medical emergency as it impairs gas exchange and can lead to respiratory failure if not promptly treated. Immediate intervention is necessary to stabilize the client's respiratory and cardiac status.

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Correct Answer is A

Explanation

Choice A reason: The arterial blood gas values pH 7.25, HCO3- 19 mEq/L, and PaCO2 30 mm Hg are indicative of metabolic acidosis, which is commonly seen in chronic kidney disease (CKD). In CKD, the kidneys lose their ability to excrete hydrogen ions and retain bicarbonate, leading to a decrease in blood pH (acidosis) and a reduction in bicarbonate (HCO3-). The PaCO2 value is slightly lower as a compensatory mechanism by the lungs to help balance the pH.

Choice B reason: The values pH 7.30, HCO3- 26 mEq/L, and PaCO2 50 mm Hg suggest a state of respiratory acidosis with partial metabolic compensation. This is not typically expected in chronic kidney disease. Respiratory acidosis occurs when there is hypoventilation, leading to an accumulation of carbon dioxide (CO2) in the blood. The bicarbonate (HCO3-) level is within the normal range, indicating that it is not the primary disorder in this context.

Choice C reason: The values pH 7.50, HCO3- 20 mEq/L, and PaCO2 32 mm Hg are consistent with respiratory alkalosis, where the pH is elevated due to hyperventilation leading to a loss of CO2. This condition is not typically associated with chronic kidney disease. The bicarbonate level is slightly below normal but not enough to indicate a significant metabolic disorder.

Choice D reason: The values pH 7.55, HCO3- 30 mEq/L, and PaCO2 31 mm Hg indicate metabolic alkalosis, which is characterized by an elevated pH and increased bicarbonate. This condition can occur due to excessive loss of acids (e.g., vomiting) or an increase in bicarbonate but is not typically expected in chronic kidney disease.

A. Explain ways to decrease paroxysmal nocturnal dyspnea. B. Discuss the effects of medications, ways to assess fluid balance, and positions for enhancing respirations. C. Teach stress management techniques. D. Provide a list of support systems in the community.

Correct Answer is B

Explanation

Choice A reason: Explaining ways to decrease paroxysmal nocturnal dyspnea is helpful for managing this specific symptom of heart failure, which involves difficulty breathing at night due to fluid accumulation in the lungs. While this can improve comfort, it doesn't provide a comprehensive approach to managing heart failure symptoms at home.

Choice B reason: Discussing the effects of medications, ways to assess fluid balance, and positions for enhancing respirations offers a comprehensive approach to managing heart failure symptoms at home. Understanding medication effects helps clients adhere to their treatment plan and manage side effects. Assessing fluid balance is crucial for detecting fluid overload early, a common issue in heart failure. Learning positions that enhance respirations can improve breathing and overall comfort.

Choice C reason: Teaching stress management techniques is beneficial for overall well-being and can indirectly improve heart health by reducing stress, which can exacerbate heart failure symptoms. However, it is not as directly related to managing the physical symptoms of heart failure as other interventions.

Choice D reason: Providing a list of support systems in the community is valuable for emotional and practical support, which can improve quality of life for clients with heart failure. However, it does not directly address the physical symptoms or management of heart failure at home.

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Which client should the telemetry nurse assess first after receiving the a.m. shift report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

Correct Answer is A

Explanation

Which instruction would best reduce the symptoms of a client with heart failure and assure more comfort at home?

Correct Answer is B

Explanation

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