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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:

A fasting triglyceride level of 167 mg/dL is above the desirable level of less than 150 mg/dL, indicating a higher risk for CAD34.

Choice B rationale:

An HDL level of 96 mg/dL is considered good and is protective against CAD34.

Choice C rationale:

An LDL level of 104 mg/dL is near optimal/above optimal, but it’s not high enough to be a priority risk factor for CAD34.

Choice D rationale:

Total serum cholesterol of 192 mg/dL is within the desirable range of less than 200 mg/dL34.

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

A. "Did you take aspirin today?". B. "Do you have any allergies?". C. "Can you rate the pain on a 0 to 10 scale?". D. "What time did your pain begin?". .

Correct Answer is D

Explanation

Choice A rationale:

While aspirin is often given to patients with suspected myocardial infarction, asking if the patient took aspirin does not help determine the timing of the onset of symptoms.

Choice B rationale:

Knowing the patient’s allergies is important for medication safety, but it does not help determine eligibility for thrombolytic therapy.

Choice C rationale:

Rating the pain on a scale helps assess the severity of the pain, but it does not provide information about the timing of the onset of symptoms.

Choice D rationale:

The time of pain onset is crucial in determining eligibility for thrombolytic therapy. Thrombolytic therapy is most effective when given within a certain time frame from the onset of symptoms.

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

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Naxlex Comprehensive Predictor Exams

The nurse is providing teaching about the patient's laboratory values that increase the risk for coronary artery disease (CAD). Which of the following values should the nurse prioritize?.

Correct Answer is A

Explanation

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?.

Correct Answer is D

Explanation

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