A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

Laboratory testing of serum potassium upon admission

Bumetanide 1 mg IV bolus every 12 hr

0.9% normal saline IV at 50 mL/hr continuous

Morphine sulfate 2 mg IV bolus every 2 hr PRN pain

Answer and Explanation

The Correct Answer is C

Choice A Reason: This choice is incorrect because laboratory testing of serum potassium upon admission is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that aﬀects the cardiac function and rhythm. A normal serum potassium range is 3.5 to 5 mEq/L, and an abnormal level can indicate hypokalemia or hyperkalemia, which can cause arrhythmias, muscle weakness, or paralysis. Therefore, monitoring serum potassium is important to detect and correct any electrolyte imbalance and prevent complications.

Choice B Reason: This choice is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that helps to reduce ﬂuid retention and edema by increasing the urine output and sodium excretion. It may be used for clients who have heart failure, hypertension, or renal impairment, but it can cause hypokalemia, hypotension, or dehydration.

Therefore, administering bumetanide as prescribed can help to improve the cardiac output and reduce the preload and afterload.

Choice C Reason: This choice is correct because 0.9% normal saline IV at 50 mL/hr continuous is an inappropriate prescription for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that contains the same concentration of solutes as blood plasma. It may be used for clients who have ﬂuid loss, dehydration, or shock, but it can worsen ﬂuid overload and pulmonary edema in clients who have acute heart failure. Therefore, clarifying this prescription with the provider is necessary to prevent further deterioration of the client's condition.

Choice D Reason: This choice is incorrect because morphine sulfate 2 mg IV bolus every 2 hr PRN pain is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that helps to relieve pain and anxiety by binding to the opioid receptors in the brain and spinal cord. It may be used for clients who have moderate to severe pain, dyspnea, or chest discomfort, but it can cause respiratory depression, hypotension, or nausea. Therefore, administering morphine sulfate as prescribed can help to reduce the oxygen demand and improve the cardiac function.

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Correct Answer is ["B","D","E"]

Explanation

Choice A Reason: This choice is incorrect because headache is not a common manifestation of ARF. Headache may be caused by various factors such as dehydration, stress, sinusitis, or migraine, but it does not indicate ARF.

Choice B Reason: This choice is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a difficulty or discomfort in breathing that aﬀects the oxygen delivery and carbon dioxide removal from the body. It may be caused by various factors such as lung disease, heart disease, anemia, or anxiety, but it indicates ARF when it is severe and persistent.

Choice C Reason: This choice is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of uneasiness or discomfort in the stomach that may precede vomiting. It may be caused by various factors such as food poisoning, motion sickness, medication side eﬀects, or pregnancy, but it does not indicate ARF.

Choice D Reason: This choice is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal (less than 90/60 mm Hg). It may be caused by various factors such as dehydration, blood loss, sepsis, or shock, but it indicates ARF when it is due to reduced cardiac output or vasodilation from hypoxia.

Choice E Reason: This choice is correct because decreased level of consciousness is a common manifestation of ARF. Decreased level of consciousness is a condition in which the person has impaired awareness or responsiveness to stimuli. It may be caused by various factors such as brain injury, stroke, seizure, or drug overdose, but it indicates ARF when it is due to increased carbon dioxide levels (hypercapnia) or decreased oxygen levels (hypoxemia) in the brain.

A. Infection B. Airway obstruction C. Paralytic ileus D. Fluid imbalance

Correct Answer is B

Explanation

Choice A Reason: Infection is a serious complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should monitor the client's wound healing, temperature, white blood cell count, and signs of sepsis, and administer antibiotics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice B Reason: Airway obstruction is the priority risk for assessment and intervention for a client who has burns of the head, neck, and chest. The nurse should assess the client's airway patency, respiratory rate, oxygen saturation, breath sounds, and signs of respiratory distress, such as stridor, wheezes, or cyanosis. The nurse should also provide humidified oxygen, suction secretions, elevate the head of the bed, and prepare for endotracheal intubation if needed. Airway obstruction can occur due to edema, inﬂammation, or inhalation injury of the upper airway, and can quickly lead to hypoxia, respiratory failure, and death.

Choice C Reason: Paralytic ileus is a potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's bowel sounds, abdominal distension, nausea, vomiting, and stool output, and administer ﬂuids, electrolytes, and nutritional support as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice D Reason: Fluid imbalance is another potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's ﬂuid status, urine output, vital signs, weight, and serum electrolytes, and administer intravenous ﬂuids as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

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A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is B

Explanation

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A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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