A client is admitted to the emergency department 5 days after an acute coronary syndrome (ACS) troubled by severe fatigue, muscle weakness, and shortness of breath. The client's electrocardiogram (ECG) Indicates sinus tachycardia and the laboratory findings indicate an elevated serum brain natriuretic peptide (BNP) level. Which action is most important for the nurse to implement?

Insert an indwelling urinary catheter.

Obtain blood for serum cardiac enzymes.

Provide emotional support.

Auscultate lung fields for fine rales.

Answer and Explanation

The Correct Answer is D

A.   Inserting an indwelling urinary catheter may be considered if the client is unable to urinate or if precise measurement of urine output is crucial for assessing fluid status. However, in this context, the immediate concern is more likely related to the client's cardiovascular status and respiratory symptoms rather than urinary output.
B.   Serum cardiac enzymes (such as troponin, CK-MB) are important for diagnosing acute myocardial infarction or myocardial injury. While this is relevant for assessing cardiac damage, the elevated BNP level and current symptoms suggest that heart failure or fluid overload might be more pressing concerns.

C.   Emotional support is important for any patient, especially those dealing with significant health issues. However, in this situation, the priority should be on addressing the immediate physiological concerns related to the client's symptoms and laboratory findings. Emotional support can be provided alongside other clinical interventions but should not be the primary action in this acute setting.
D.   Fine rales (or crackles) in the lung fields are often associated with pulmonary congestion or fluid
overload, which are common in heart failure. Given the elevated BNP level and the client’s symptoms of
shortness of breath and fatigue, assessing the lung fields for rales is crucial.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The absence of hair growth on the lower legs is a potential sign of peripheral neuropathy, a common complication of diabetes. Assessing the skin for other signs of neuropathy, such as dryness, cracking, or calluses, would provide further evidence to support this diagnosis.
B. While this might indicate neuropathy, it's not as direct a correlation as the skin appearance.
C. Assessing pulses helps to evaluate peripheral circulation, but it doesn't directly address the issue of hair loss, which is more related to nerve damage.
D. Ecchymosis can indicate a bleeding disorder or trauma, not necessarily neuropathy.

A. Anxiety B. Hyperglycemia C. Fever D. Dyspnea.

Correct Answer is D

Explanation

A. Anxiety is a common symptom in patients with thyrotoxicosis due to increased metabolic activity and overstimulation of the nervous system. While anxiety can be distressing, it is not typically life- threatening and does not usually require immediate intervention.
B. Hyperglycemia (high blood glucose levels) can occur in patients with thyrotoxicosis due to increased metabolic rate and potential effects on insulin sensitivity. It requires monitoring and management but typically does not demand immediate intervention unless it is severe and causing other complications.
C. Fever can be a sign of thyroid storm, a severe form of thyrotoxicosis that can be life-threatening. Elevated body temperature in the context of thyrotoxicosis requires prompt assessment as it may indicate an underlying severe condition or complications.
D. Dyspnea is a critical symptom that warrants immediate intervention. In the context of thyrotoxicosis, it may indicate a severe complication such as heart failure, thyroid storm, or respiratory distress. Given that dyspnea can lead to compromised oxygenation and potentially life-threatening situations, it is the most urgent symptom to address.

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Naxlex Comprehensive Predictor Exams

While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

Correct Answer is A

Explanation

A client admitted with thyrotoxicosis is reporting a "pounding heart in the chest." Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is D

Explanation

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?