A client with a history of emphysema and heart failure is admitted to the emergency department with enema, coughing, and shortness of breath. The client's laboratory value for brain natriuretic peptide is elevated. Which prescription is most important for the nurse to implement?
Administer IV furosemide.
Insert an indwelling urinary catheter.
Monitor for telemetry ST segment changes.
Give a bronchodilator per inhaler.
The Correct Answer is A
Choice A reason: Administering IV furosemide (a diuretic) is crucial for managing the client's symptoms of fluid overload, as indicated by enema and elevated brain natriuretic peptide (BNP) levels. Furosemide helps reduce the volume of fluid in the body, relieving symptoms of heart failure and improving breathing. It addresses the most urgent need for the client.
Choice B reason: Inserting an indwelling urinary catheter might be necessary for accurate measurement of urine output, especially in a client receiving diuretic therapy. However, it is not the most immediate intervention needed to stabilize the client's condition.
Choice C reason: Monitoring for telemetry ST segment changes is important for clients with cardiac conditions. While it is necessary for ongoing assessment, it does not address the immediate need to relieve fluid overload and improve the client's respiratory status.
Choice D reason: Giving a bronchodilator per inhaler can help with respiratory symptoms related to emphysema. However, in this scenario, the primary issue is fluid overload due to heart failure, which needs to be addressed first with diuretic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Step 1: Convert the client's weight from pounds to kilograms. 176 pounds ÷ 2.2 = 80 kg
Step 2: Determine the total units of insulin needed per hour. 80 kg × 0.1 unit/kg/hour = 8 units/hour
Step 3: Determine the volume of insulin solution needed per hour. (8 units) ÷ (100 units/100 mL) = (8 units) ÷ (1 unit/mL) = 8 mL/hour
So, the nurse should set the infusion pump to deliver 8 mL/hour.
Correct Answer is D
Explanation
Choice A reason: Frequency of sexual activity can provide useful information about the client's sexual health and habits, but it is not the most critical information needed to address erectile dysfunction. The nurse needs to determine if there are any immediate factors contributing to ED, such as medication side effects.
Choice B reason: Environmental toxin exposure can have long-term health effects, including on sexual function. However, it is not the most urgent factor to consider when evaluating a client with erectile dysfunction. Immediate information about medications and medical history is more pertinent.
Choice C reason: Familial history of diabetes is important because diabetes can affect erectile function due to vascular and neurological complications. Yet, while this background information is useful, it is not the most immediate concern compared to potential medication side effects.
Choice D reason: The current medication regimen is the most important information for the nurse to obtain. Many medications can contribute to erectile dysfunction as a side effect. By identifying the medications the client is taking, the nurse can determine if ED might be a side effect and discuss possible adjustments or alternatives with the healthcare provider.
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