A client with a diagnosis of heart failure is admitted to the cardiac unit. Which intervention should the nurse complete first?

Draw a basic metabolic panel (BMP) for a potassium level

Obtain a health history

Auscultate the lung and heart sounds

Assess the pulse and temperature

Answer and Explanation

The Correct Answer is C

A. Drawing a basic metabolic panel (BMP) is important for monitoring electrolyte imbalances, especially potassium in clients on diuretics, but it is not the priority intervention.
B. Obtaining a health history is necessary, but assessing the client’s current status takes priority in an acute setting.
C. Auscultating the lung and heart sounds is correct. In heart failure, pulmonary congestion and fluid overload can quickly lead to respiratory distress. The nurse should immediately assess for crackles, wheezing, or signs of pulmonary edema, as well as abnormal heart sounds that may indicate worsening heart failure.
D. Assessing pulse and temperature is routine, but assessing lung and heart sounds directly evaluates for acute decompensation and should be prioritized.

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Correct Answer is A

Explanation

A. Atherosclerosis is correct. It is the primary cause of myocardial infarction (MI) due to the narrowing and eventual blockage of coronary arteries by plaque buildup, leading to reduced oxygen supply to the heart muscle.
B. Obesity is a risk factor for MI but is not the direct cause. It contributes to conditions like hypertension, diabetes, and atherosclerosis, which increase MI risk.
C. Hypertension increases the risk of MI by damaging blood vessels over time, but it is not the most common direct cause.
D. Diabetes Mellitus type 2 is a risk factor because it contributes to vascular damage and atherosclerosis, but it is not the primary cause of an MI.

A. Obtain intravenous access. B. Obtain the client's family history. C. Apply continuous ECG monitoring. D. Administer 02 to maintain oxygen saturation greater than 90%.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Obtain intravenous (IV) access: IV access is necessary for administering medications, fluids, and emergency interventions.
Obtain the client's family history: While family history is important for long-term cardiac risk assessment, it is not a priority in the acute phase of chest pain management.
Apply continuous ECG monitoring: Continuous ECG monitoring is critical for detecting arrhythmias, ischemic changes, and potential myocardial infarction (MI).
Administer O₂ to maintain oxygen saturation greater than 90%: Oxygen therapy is indicated in clients with suspected MI if their oxygen saturation is below 90% to prevent further myocardial ischemia.

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A client with a diagnosis of heart failure is admitted to the cardiac unit. Which intervention should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies which of the following as the most common cause of a myocardial infarction?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

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