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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Cold intolerance is a common symptom of hypothyroidism due to the reduced metabolic rate. While it is important to address this symptom, it does not require immediate intervention compared to respiratory issues.

Choice B reason: Weight gain is also a common symptom of hypothyroidism because of the decreased metabolism. It is significant but not immediately life-threatening, so it does not take priority over more urgent conditions.

Choice C reason: Hypoventilation is the most critical finding because it indicates respiratory depression. This can lead to severe hypoxia and carbon dioxide retention, potentially causing life-threatening complications. Immediate intervention is required to support the client's breathing and prevent respiratory failure.

Choice D reason: Lethargy is a common symptom of hypothyroidism due to the overall slowing of the body's functions. While concerning, it is not as immediately dangerous as hypoventilation, which directly affects the client's ability to breathe effectively.

A. Minimize intake of spicy foods. B. Begin a smoking cessation program. C. Avoid wearing tight-fitting clothes. D. Remain upright following meals.

Correct Answer is D

Explanation

Choice A reason: Minimizing the intake of spicy foods can help reduce GERD symptoms, but it is not the most critical instruction for preventing reflux immediately after eating.

Choice B reason: Beginning a smoking cessation program is important for overall health and can help reduce GERD symptoms over time, but it is not the immediate priority for preventing reflux.

Choice C reason: Avoiding tight-fitting clothes can help reduce pressure on the abdomen and lessen reflux symptoms, but it is not the most urgent instruction to emphasize at discharge.

Choice D reason: Remaining upright following meals is crucial for preventing reflux. Lying down immediately after eating can cause stomach contents to flow back into the oesophagus, exacerbating GERD symptoms. This instruction is key to managing the condition effectively.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Correct Answer is C

Explanation

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

Correct Answer is D

Explanation

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To ensure client adherence to the postoperative regimen, which content is most important for the nurse to include in the preoperative teaching?

The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?

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A client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. Which action should the nurse implement?

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