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 D

Explanation

A. Check for orthostatic hypotension. While important, checking for orthostatic hypotension is not the priority action in a hypertensive emergency, where rapid blood pressure reduction is necessary.

B. Assist the client to make lifestyle changes. Assisting the client with lifestyle changes is part of long-term blood pressure management but is not a priority action when administering nicardipine for acute hypertension.

C. Instruct the client to restrict sodium intake. Sodium restriction is a key component of managing hypertension but is not the priority action during an acute hypertensive crisis.

D. Monitor the client's BP every 5 minutes. In a hypertensive crisis, frequent monitoring of the client’s blood pressure is essential to ensure the medication is lowering blood pressure safely and effectively.

A. Smoking B. Obesity C. Genetic predisposition D. Hypertension E. Hypercholesterolemia

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

Explanation

A. Smoking: Smoking is a major modifiable risk factor for atherosclerosis. Cessation can significantly reduce the risk of disease progression.

B. Obesity: Obesity is a modifiable risk factor. Weight loss through diet and exercise can help lower the risk of atherosclerosis.

C. Genetic predisposition: Genetic predisposition is a non-modifiable risk factor. It cannot be changed or controlled, so it is not considered a modifiable factor.

D. Hypertension: Hypertension is a modifiable risk factor, as it can be managed through lifestyle changes and medication.

E. Hypercholesterolemia: Hypercholesterolemia (high cholesterol levels) is a modifiable risk factor because it can be controlled through diet, exercise, and medication.

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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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Explanation

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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.