A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider?
Chest x-ray showing cardiomegaly
PaCO2 55 mmHg
Potassium level 4.5 mEq/L
Urinary output of 1,000 mL in 12 hr
The Correct Answer is B
Choice A reason: Chest x-ray showing cardiomegaly is not a new finding for the client who has heart failure, as it indicates enlargement of the heart due to increased workload and pressure on the cardiac chambers.
Choice B reason: PaCO2 55 mmHg is an abnormal finding for the client who has heart failure, as it indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pulmonary edema, which is a complication of heart failure that impairs gas exchange and ventilation.
Choice C reason: Potassium level 4.5 mEq/L is a normal finding for the client who has heart failure, as it indicates adequate electrolyte balance and renal function.
Choice D reason: Urinary output of 1,000 mL in 12 hr is a normal finding for the client who has heart failure, as it indicates adequate fluid status and cardiac output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C Hemoglobin 8.6 g/dL indicates the nurse should notify the provider because it is below the normal range of 12 to 18 g/dL and suggests blood loss or anemia, which can impair oxygen delivery to tissues and affect wound healing.
Choice a is not correct because blood glucose 98 mg/dL does not indicate the nurse should notify the provider because it is within the normal range of 70 to 110 mg/dL and does not indicate hyperglycemia or hypoglycemia, which can affect recovery.
Choice b is not correct because BUN 18 mg/dL does not indicate the nurse should notify the provider because it is within the normal range of 10 to 20 mg/dL and does not indicate renal impairment or dehydration, which can affect fluid and electrolyte balance.
Choice d is not correct because potassium 3.5 mEq/L does not indicate the nurse should notify the provider because it is within the normal range of 3.5 to 5 mEq/L and does not indicate hypokalemia or hyperkalemia, which can affect cardiac function and muscle contraction.
Correct Answer is d,b,e,a,c
Explanation
The sequence the nurse should use to administer the medication using the Z-track technique is:
- Step 1: Put on gloves and cleanse the site with an antiseptic swab.
- Step 2: Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally.
- Step 3: Insert the needle into the muscle.
- Step 4: Aspirate by pulling back on the plunger and inject the medication.
- Step 5: Remove the needle and release the tissue.
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