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":{"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.

A. "Try taking a mild analgesic to relieve the headache." B. "Take only one dose of nitroglycerin to reduce the risk of getting a headache." C. "We will ask the provider to prescribe a different medication for you." D. "There's nothing that can be done to relieve the headaches that nitroglycerin causes."

Correct Answer is A

Explanation

A. "Try taking a mild analgesic to relieve the headache." is correct. Nitroglycerin-induced headaches are a common side effect due to vasodilation. Mild analgesics such as acetaminophen can help alleviate the discomfort.
B. Taking only one dose to reduce the risk of a headache is inappropriate. The client should follow the prescribed dosing regimen to manage angina effectively. Skipping doses may increase the risk of angina attacks.
C. Requesting a different medication is not necessary. Nitroglycerin is an effective treatment for stable angina, and headaches typically diminish over time as the body adjusts to the medication.
D. Stating that nothing can be done to relieve the headaches is incorrect. Headaches from nitroglycerin can be managed with mild analgesics or by adjusting the timing of medication administration.

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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

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

Explanation

A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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