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 C

Explanation

A. Aim for a total cholesterol at 225 mg/dL. A total cholesterol level of 225 mg/dL is higher than the recommended target, which is typically less than 200 mg/dL. This is not an appropriate treatment goal.

B. Maintain blood pressure at less than 140/90 mm Hg. This is a reasonable goal for many clients with atherosclerosis. Keeping blood pressure below 140/90 mm Hg helps reduce the risk of further vascular damage.

C. Limit total fat intake to 50% of total daily calories. Limiting fat intake to 50% of total daily calories is excessive. The recommendation is usually around 25-35% of total daily calories from fat, with a focus on healthy fats.

D. Keep body mass index (BMI) above 30. A BMI above 30 is classified as obese, which is a risk factor for atherosclerosis. The goal is to reduce BMI to within a healthy range (18.5-24.9).

A. CT scan without contrast dye B. Echocardiogram C. Electrocardiogram D. Nuclear stress test

Correct Answer is D

Explanation

A. CT scan without contrast dye: A CT scan without contrast dye is a non-invasive diagnostic procedure that does not require written informed consent in most cases.

B. Echocardiogram: An echocardiogram is a non-invasive ultrasound of the heart and typically does not require written informed consent.

C. Electrocardiogram: An electrocardiogram (ECG) is a simple, non-invasive test to monitor heart activity and does not require written informed consent.

D. Nuclear stress test: A nuclear stress test involves injecting a radioactive substance and placing stress on the heart. Due to its invasive nature and potential risks, written informed consent is required for this procedure.

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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.