A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation.
Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
Irregular pulse.
Persistent fatigue.
Dependent edema.
Slurred speech.
The Correct Answer is D
Choice A rationale
Irregular pulse. While an irregular pulse is a common finding in atrial fibrillation, it is not the most critical finding to report immediately unless it is associated with other symptoms.
Choice B rationale
Persistent fatigue. Persistent fatigue is a common symptom in heart failure and atrial fibrillation but does not require immediate reporting unless it worsens significantly.
Choice C rationale
Dependent edema. Dependent edema is a common symptom in heart failure but does not require immediate reporting unless it is severe or worsening rapidly.
Choice D rationale
Slurred speech. This finding is critical to report immediately as it may indicate a stroke or transient ischemic attack (TIA) due to an embolus from atrial fibrillation. Prompt intervention is necessary to prevent further complications. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
9 percent is the percentage of total body surface area (TBSA) for one arm (front or back) or the head and neck combined. Since the burns are on the front and back of both arms, this percentage is too low.
Choice B rationale
18 percent is the correct percentage of TBSA for burns on the front and back of both arms. Each arm accounts for 9 percent of TBSA, so both arms together account for 18 percent.
Choice C rationale
36 percent is the percentage of TBSA for burns on both legs (front and back) or the entire trunk (anterior and posterior). This percentage is too high for burns on the front and back of both arms.
Choice D rationale
54 percent is the percentage of TBSA for burns on the entire trunk (anterior and posterior) and one leg (front and back). This percentage is too high for burns on the front and back of both arms.
Correct Answer is B
Explanation
Choice A rationale
While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.
Choice B rationale
Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.
Choice C rationale
Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.
Choice D rationale
Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.
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