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
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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Related Questions
Correct Answer is B
Explanation
A. Taking 4 tablets over 20 minutes exceeds the recommended limit of 3 doses in 15 minutes and can dangerously delay emergency care if the pain is due to a heart attack.
B. The correct teaching is to take 1 sublingual nitroglycerin tablet at the onset of angina and, if pain persists after 5 minutes, activate emergency services while taking up to 2 additional tablets at 5-minute intervals. This ensures rapid symptom relief while promptly initiating emergency care if the angina does not resolve.
C. Calling 911 before taking any nitroglycerin delays immediate treatment of angina. Sublingual nitroglycerin is meant to relieve pain quickly, so contacting emergency services comes after assessing response to the first dose.
D. Waiting until all 3 tablets are taken before calling 911 can dangerously delay care if the angina is progressing to myocardial infarction. Early activation after the first dose ensures patient safety and timely intervention.
Correct Answer is C
Explanation
A. Brain Natriuretic Peptide (BNP) is a marker for heart failure, not the primary diagnostic test for myocardial infarction (MI).
B. Total Lactate Dehydrogenase (LDH) was historically used but is not specific for MI and has been replaced by troponin testing.
C. Troponin is correct. Cardiac-specific troponins (Troponin I and Troponin T) are the gold standard for detecting myocardial injury. Elevated levels indicate myocardial damage and are crucial for diagnosing MI.
D. Creatinine is important for assessing kidney function but is not a marker for myocardial infarction.
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