A nurse is assisting with the admission of a client who has a history of heart failure.

Exhibits

Which of the following findings require immediate follow-up by the nurse? Select all that apply.

Neurological assessment

Vital signs

Basic Metabolic Profile (BMP) laboratory report

Cardiac enzymes laboratory report

B-natriuretic peptide (BNP) laboratory report

Respiratory assessment

Answer and Explanation

Correct Answer : B,D,E,F,G

A. Neurological assessment: The neurological assessment indicates the client is alert and oriented, which is good; however, it does not require immediate follow-up.

B. Vital signs: The vital signs indicate an elevated heart rate (138/min), elevated respiratory rate (28/min), and borderline low blood pressure (96/75 mm Hg). These findings suggest potential hemodynamic instability and require immediate attention to assess the underlying cause and determine the appropriate interventions.

C. Basic Metabolic Profile (BMP) laboratory report: The BMP is largely within normal limits except for the glucose level (148 mg/dL), which is slightly elevated but not critically so. There is no urgent need for follow-up based on the BMP findings unless other symptoms arise.

D. Cardiac enzymes laboratory report: The troponin level is elevated (10.1 ng/mL), indicating myocardial injury, which requires immediate follow-up to assess the risk of acute coronary syndrome or worsening heart failure. This is a critical finding that warrants further evaluation.

E. B-natriuretic peptide (BNP) laboratory report: The BNP level is significantly elevated at 800 ng/mL, indicating worsening heart failure. This finding requires immediate follow-up to assess the client's condition and determine appropriate management strategies.

F. Respiratory assessment: The respiratory assessment shows an elevated respiratory rate (28/min) and oxygen saturation at 93% on supplemental oxygen. The presence of pink-tinged sputum may indicate pulmonary congestion or possible pulmonary edema, necessitating immediate follow-up.

G. ECG report: The ECG shows atrial fibrillation with a rapid ventricular response (RVR) at a rate of 135/min. This irregular heart rate can lead to decreased cardiac output and increased risk of thromboembolic events, requiring immediate follow-up to manage the heart rate and rhythm appropriately.

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Correct Answer is A

Explanation

A. Count the apical pulsations for a full minute. The apical pulse should be counted for a full minute to ensure accuracy, especially in clients taking cardiovascular medications, as these may affect heart rhythm and rate.

B. Place the stethoscope just under the mid-clavicular area of the left chest. The apical pulse is typically located at the fifth intercostal space at the midclavicular line, not directly under the clavicle.

C. Press the stethoscope firmly against the client's skin. While the stethoscope needs to be in full contact with the skin, excessive pressure is not necessary and may distort the sound.

D. Check the apical pulse with a Doppler device. A Doppler is typically used when the pulse is difficult to palpate or auscultate, not as a first-line method for checking the apical pulse.

A. Liver B. Beans C. Eggs D. Milk

Correct Answer is B

Explanation

A. Liver: Liver is high in cholesterol and should be avoided by clients on a low-cholesterol diet. This is not a suitable choice for the client.

B. Beans: Beans are a high-fiber, plant-based protein source that is low in cholesterol. This is a good choice for a low-cholesterol diet.

C. Eggs: Eggs contain cholesterol, particularly in the yolk. While one egg a day may be acceptable for some individuals, this is generally a food that should be limited on a low-cholesterol diet.

D. Milk: Depending on the fat content, milk can be high in cholesterol. Clients should opt for skim or low-fat milk to reduce cholesterol intake. Full-fat milk is not ideal for a low-cholesterol diet.

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A nurse is assisting with the admission of a client who has a history of heart failure. Exhibits Which of the following findings require immediate follow-up by the nurse? Select all that apply.

Nursing Test Bank

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A nurse is assisting with the admission of a client who has a history of heart failure.

Exhibits

Which of the following findings require immediate follow-up by the nurse? Select all that apply.