A nurse is admitting a client who has a history of heart failure.
Check the 5 findings that require immediate follow-up.
Vital signs
Respiratory assessment
Renal function
Cardiac enzymes
BNP
ECG results
Neurologic status
Correct Answer : A,B,C,E,F
A. Vital signs . The client has tachycardia (HR 138/min) and tachypnea (RR 28/min), which may indicate worsening heart failure or fluid overload. The low blood pressure (96/75 mmHg) is also concerning, especially with rapid ventricular response (RVR).
B. Respiratory assessment . The presence of a frequent cough with pink-tinged sputum suggests pulmonary congestion or pulmonary edema, a sign of worsening left-sided heart failure.
C. Renal function . The BUN of 28 mg/dL (elevated) and creatinine of 1.5 mg/dL (borderline high) suggest possible kidney impairment due to decreased cardiac output and poor perfusion.
D. Cardiac enzymes . The client denies chest pain or discomfort, so cardiac enzymes are not the immediate priority.
E. BNP (B-type natriuretic peptide) . BNP is a key marker of heart failure severity and helps guide treatment decisions.
F. ECG results . The atrial fibrillation with RVR increases the risk of hemodynamic instability and potential thromboembolic events, requiring urgent intervention.
G. Neurologic status . The client is alert, oriented, and following commands, so no immediate neurologic concerns are present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Orthopnea is correct. Left-sided heart failure causes pulmonary congestion, making it difficult for the client to breathe when lying flat. This results in orthopnea, where the client must sit up or use multiple pillows to breathe comfortably.
B. Bradycardia is incorrect. Heart failure typically leads to tachycardia due to the heart compensating for decreased cardiac output.
C. Diaphoresis is incorrect. While excessive sweating can occur in acute decompensated heart failure, it is not a hallmark symptom of left-sided heart failure.
D. Frequent coughing with yellow sputum is incorrect. A client with left-sided heart failure may have a dry or frothy, pink-tinged cough, but yellow sputum suggests infection rather than heart failure.
Correct Answer is A
Explanation
A. Pleural effusion is a common complication of heart failure. Increased pressure in the pulmonary circulation can cause fluid to accumulate in the pleural space, leading to dyspnea and decreased lung expansion.
B. Infection is not a direct complication of heart failure. However, individuals with heart failure may have an increased risk of infections due to a weakened immune system.
C. Asthma is not a complication of heart failure. While both conditions can cause shortness of breath, asthma is a separate respiratory disorder.
D. Hemorrhage is not associated with heart failure. Instead, heart failure can lead to clotting abnormalities or increased bleeding risk if the client is on anticoagulants.
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