Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who has heart failure.

Nurses' Notes.

Day 1: Vital Signs.

Bilateral breath sounds clear and present throughout.

Weight 80 kg (176 lb). Urine output 480 mL/8 hr. Day 4: Breath sounds scattered, crackles heard bilaterally.

Apical heart rate rapid and irregular.

Audible S3 gallop.

Weight 82.1 kg (181 lb). Urine output 320 mL/8 hr. Vital Signs.

Day 1: Temperature 37.6° C (99.7° F). Blood pressure 108/50 mm Hg. Pulse 98/min.

Respiratory rate 20/min.

Pulse oximetry 95% on room air.

Day 4: Temperature 36.8° C (98.2° F). Blood pressure 138/80 mm Hg. Pulse 112/min.

Respiratory rate 28/min.

Pulse oximetry 88% on room air.

A nurse is reviewing the assessment findings for the client on day 4. Which of the following findings requires further action? (Select all that apply.).

Temperature.

Oxygen saturation.

Blood pressure.

Weight.

Urine output.

Breath sounds.

Answer and Explanation

Correct Answer : B,C,D,F

Choice A rationale:

The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.

Choice B rationale:

The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.

Choice C rationale:

The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.

Choice D rationale:

The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.

Choice E rationale:

The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function

Choice F rationale:

On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.

So, the correct answer is Choices B, C, D, and F, after analyzing all choices.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

An increase in heart rate from 66 to 98 beats/min indicates that the heart is working harder, which could be a sign of stress or exertion. This is a significant increase and could indicate that the patient needs to rest.

Choice B rationale:

While a drop in O2 saturation from 99% to 95% is noticeable, it is still within the normal range (95-100%). Therefore, it would not necessarily indicate a need for the patient to rest.

Choice C rationale:

A respiratory rate increase from 14 to 20 breaths/min is within the normal range (12-20 breaths/min) and would not necessarily indicate a need for the patient to rest.

Choice D rationale:

A blood pressure change from 118/60 to 126/68 mm Hg is within the normal range and would not necessarily indicate a need for the patient to rest.

So, the correct answer is Choice A, after analyzing all choices.

A. Right upper-sternal border. B. Left upper-sternal border. C. Left lower-sternal border. D. Apex. E. Apex.

Correct Answer is D

Explanation

Choice A rationale:

The right upper-sternal border is not the best place to hear a murmur typical of mitral regurgitation.

Choice B rationale:

The left upper-sternal border is not the best place to hear a murmur typical of mitral regurgitation.

Choice C rationale:

The left lower-sternal border is not the best place to hear a murmur typical of mitral regurgitation.

Choice D rationale:

The apex of the heart is the best place to hear a murmur typical of mitral regurgitation. This is where the sound will be most audible.

So, the correct answer is Choice D, after analyzing all choices.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest?.

Correct Answer is A

Explanation

The nurse is caring for a patient with mitral regurgitation. Where would the nurse listen to best hear a murmur typical of mitral regurgitation?.

Correct Answer is D

Explanation

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain may be from an acute myocardial infarction?.

A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?.

Which patient statement would help the nurse confirm the previous diagnosis of chronic stable angina?.

The nurse is assessing a patient with myocarditis before giving a scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider?.

Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been effective?

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication would the nurse question before giving?.