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 D

Explanation

A. Heart failure is associated with central sleep apnea, not obstructive sleep apnea (OSA), which results from airway obstruction.
B. Opioid overdose is linked to central sleep apnea, where the brain fails to send proper signals to the breathing muscles. It does not cause obstruction of the airway.
C. Brainstem injury can affect respiratory drive, but it is not a direct cause of OSA, which is due to mechanical airway obstruction.
D. Enlarged tonsils are correct. In children and adults, enlarged tonsils can block the airway, making them a common cause of OSA.

A. To increase caloric intake by snacking throughout the day B. To allow for more social interaction during meals C. To ensure all food groups are consumed daily D. To reduce the risk of dyspnea during meals

Correct Answer is D

Explanation

A. While increasing caloric intake is important, the primary reason for small, frequent meals is to prevent dyspnea.
B. Social interaction is beneficial, but it is not the main reason for recommending small, frequent meals.
C. Ensuring a balanced diet is important, but not the specific reason for this recommendation.
D. Eating large meals can cause abdominal distention and pressure on the diaphragm, leading to dyspnea. Small, frequent meals help prevent this.

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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

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