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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Correct Answer is D

Explanation

A. These symptoms indicate a urinary tract issue but do not necessarily indicate a high risk for injury. While they are uncomfortable, they do not typically lead to physical harm.
B. Azotemia is the build-up of waste products in the blood, and anorexia is a loss of appetite. These symptoms indicate a more severe kidney problem and do not specifically point to an increased risk of injury due to a potential UTI.
C. These symptoms suggest kidney involvement but do not necessarily indicate an imminent risk of injury. While they are important to address, they do not warrant the nursing problem of "high risk for injury due to potential urinary tract infection."

D. Fever and dysuria are classic symptoms of a urinary tract infection (UTI). A UTI can progress to a more serious infection, such as pyelonephritis, which can lead to sepsis and potentially life-threatening complications. Therefore, these symptoms indicate a high risk for injury due to the potential for a UTI to worsen.

A. Calcium level 7.2 mg/dL (1.8 mmol/L). B. Potassium level 3.8 mg/dl. (3.8 mmol) C. Sodium level 140 mEq/L (140mmol/L). D. Oxygen saturation level 97%.

Correct Answer is A

Explanation

A. This calcium level is below the normal reference range (8.4 to 10.6 mg/dL or 2.10 to 2.50 mmol/L), indicating hypocalcemia. Calcium plays a crucial role in cardiac muscle contraction and electrical conduction. Low calcium levels can lead to various cardiac dysrhythmias, including prolonged QT intervals and increased risk of ventricular arrhythmias.

B. This potassium level falls within the normal range (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L). Potassium is essential for maintaining normal cardiac rhythm, but a level of 3.8 mg/dL is not abnormal and, therefore, is less likely to be the cause of a dysrhythmia compared to abnormal levels.
C. This sodium level is within the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L). Sodium levels typically do not directly cause dysrhythmias unless they are extremely high or low, which is not the case here. Thus, a sodium level of 140 mEq/L is not likely to be the primary contributor to the dysrhythmia.
D. This oxygen saturation level is considered normal (95% to 100%). While oxygenation is critical for overall heart function and can influence cardiac health, a saturation level of 97% is not likely to be a direct cause of a dysrhythmia, especially if it falls within the normal range.

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Naxlex Comprehensive Predictor Exams

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] .

Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?