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","B","C","E","F"]

Explanation

A. Vital signs . The client has tachycardia (HR 138/min) and tachypnea (RR 28/min), which may indicate worsening heart failure or fluid overload. The low blood pressure (96/75 mmHg) is also concerning, especially with rapid ventricular response (RVR).
B. Respiratory assessment . The presence of a frequent cough with pink-tinged sputum suggests pulmonary congestion or pulmonary edema, a sign of worsening left-sided heart failure.
C. Renal function . The BUN of 28 mg/dL (elevated) and creatinine of 1.5 mg/dL (borderline high) suggest possible kidney impairment due to decreased cardiac output and poor perfusion.
D. Cardiac enzymes . The client denies chest pain or discomfort, so cardiac enzymes are not the immediate priority.
E. BNP (B-type natriuretic peptide) . BNP is a key marker of heart failure severity and helps guide treatment decisions.
F. ECG results . The atrial fibrillation with RVR increases the risk of hemodynamic instability and potential thromboembolic events, requiring urgent intervention.
G. Neurologic status . The client is alert, oriented, and following commands, so no immediate neurologic concerns are present.

A. Stress testing B. D-Dimer C. Electrocardiogram D. Pulmonary function testing

Correct Answer is B

Explanation

A. Stress testing evaluates cardiac function and ischemia but is not used to diagnose a pulmonary embolism (PE).
B. D-Dimer is correct. D-Dimer is a blood test that detects fibrin degradation products, which are elevated when a blood clot forms and breaks down, making it a useful screening test for pulmonary embolism. However, a positive D-Dimer is not diagnostic, and further imaging (e.g., CT pulmonary angiography) is required.
C. Electrocardiogram (ECG) may show changes (e.g., sinus tachycardia, right heart strain) but does not confirm PE.
D. Pulmonary function testing assesses lung diseases like COPD or asthma but is not used to diagnose PE.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has a history of heart failure. Exhibits Check the 5 findings that require immediate follow-up.

Correct Answer is ["A","B","C","E","F"]

Explanation

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Correct Answer is B

Explanation

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