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A nurse is admitting a client who has a history of heart failure.

Exhibits

Check the 5 findings that require immediate follow-up.

Vital signs

Respiratory assessment

Renal function

Cardiac enzymes

BNP

ECG results

Neurologic status

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Obtaining an ECG is important but not the first priority. The immediate goal is to reduce the heart's oxygen demand.
B. Having the client sit down immediately is correct. Stopping activity reduces cardiac workload and oxygen demand, preventing further ischemia or infarction.
C. Assessing vital signs is important but should be done after stopping activity. While vital signs provide critical information, immediate intervention is needed first.
D. Administering sublingual nitroglycerin is appropriate but should be done after ensuring the client is seated. This prevents hypotension and syncope from occurring while standing.

A. A complete occlusion of the coronary artery B. Chest pain upon exertion that resolves with rest C. A partial occlusion of the coronary artery D. Chest pain while at rest

Correct Answer is C

Explanation

A. A complete occlusion of the coronary artery is characteristic of an ST-segment elevation myocardial infarction (STEMI), not an NSTEMI.
B. Chest pain that resolves with rest is more indicative of stable angina rather than NSTEMI.
C. An NSTEMI occurs due to a partial occlusion of a coronary artery, leading to myocardial ischemia and damage without ST-segment elevation on an ECG.
D. Chest pain at rest can be seen in both unstable angina and NSTEMI, but it is not the defining feature of NSTEMI.

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A nurse is admitting a client who has a history of heart failure. Exhibits Check the 5 findings that require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

The nurse is providing care for a client admitted to rule out a myocardial infarction who is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?

Correct Answer is B

Explanation

Which of the following describe a non-ST segment elevation myocardial infarction (NSTEMI)?

Correct Answer is C

Explanation

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A nurse is admitting a client who has a history of heart failure.

Exhibits

Check the 5 findings that require immediate follow-up.