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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.

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Correct Answer is A

Explanation

Choice A rationale:

Elevated troponin is a sign of heart damage, which could be caused by a heart attack or other stresses on the heart. This is a critical finding that needs immediate attention.

Choice B rationale:

Q waves on an ECG can indicate a previous heart attack or myocardial infarction. However, they can also be a normal variant, meaning they are a harmless variation in the electrical activity of the heart.

Choice C rationale:

Bilateral crackles in the lungs can indicate mucus or fluid in the base of the lungs, often associated with conditions like pneumonia, heart failure, or bronchitis.

Choice D rationale:

Hyperglycemia, or high blood glucose, can be a sign of diabetes. If untreated, it can lead to serious complications like ketoacidosis.

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

A. "I can expect nausea as a side effect of nitroglycerin.”. B. "I will store the medication in a well-lit room.”. C. "I will call an ambulance if I have pain 5 minutes after taking nitroglycerin.”. D. "I should only take nitroglycerin when I have chest pain.”.

Correct Answer is C

Explanation

Choice A rationale:

Nitroglycerin can cause side effects such as headache and dizziness, but nausea is not a common side effect.

Choice B rationale:

Nitroglycerin should be stored in a dark, cool place, not in a well-lit room.

Choice C rationale:

This is the correct answer. If chest pain is not relieved 5 minutes after taking nitroglycerin, it is recommended to call an ambulance.

Choice D rationale:

While nitroglycerin is taken when chest pain occurs, it can also be taken prior to activities that might cause chest pain.

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

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Naxlex Comprehensive Predictor Exams

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information is most important for the nurse to communicate to the health care provider?.

Correct Answer is A

Explanation

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective?.

Correct Answer is C

Explanation

Which data indicates to the nurse that the patient with stable angina is experiencing a side effect of metoprolol?.

A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse. Which of the following initial questions posed by the nurse is MOST appropriate?.

A patient has pain due to acute pericarditis. Which action would the nurse take?.

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 is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?.

A patient is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question would the nurse ask to determine whether the patient is a candidate for thrombolytic therapy?.