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. "I will sit on the side of the bed before I stand up." Propranolol can cause orthostatic hypotension, so the client should sit on the edge of the bed before standing to avoid dizziness or falls. This statement shows correct understanding.

B. "I should weigh myself on the same day once a week." Clients taking propranolol, especially if they have heart failure, should weigh themselves daily to monitor for fluid retention. Weekly weighing is insufficient for identifying early signs of worsening heart failure.

C. "I should expect to develop a slight cough while taking this medication." A cough is more commonly associated with ACE inhibitors (such as lisinopril) rather than beta-blockers like propranolol. This statement indicates a misunderstanding.

D. "I will not take my medicine if my heart rate is greater than 70/min." Beta-blockers like propranolol are typically withheld if the heart rate is below 60 beats per minute, not when it is greater than 70. This statement shows a misunderstanding of when to hold the medication.

A. Hypertension stage 2 B. Elevated or Prehypertension C. Hypertension stage 1 D. Within the expected reference range

Correct Answer is B

Explanation

A. Hypertension stage 2: Hypertension stage 2 is defined as a systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg. The client’s reading of 124/74 mm Hg does not fall into this category.

B. Elevated or Prehypertension: A systolic blood pressure between 120-129 mm Hg and a diastolic <80 mm Hg is classified as elevated or prehypertension. The client’s systolic BP of 124 mm Hg places him in this category.

C. Hypertension stage 1: Hypertension stage 1 is defined as a systolic BP between 130-139 mm Hg or diastolic BP between 80-89 mm Hg. The client’s BP of 124/74 mm Hg does not meet this criterion.

D. Within the expected reference range: The normal range for blood pressure is less than 120/80 mm Hg. The client’s BP of 124/74 mm Hg is slightly elevated and does not fall within the expected reference range.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has hypertension and is taking propranolol. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/74 mm Hg places him in which of the following categories or stages?

Correct Answer is B

Explanation

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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.