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 D
Explanation
Choice A reason: Maintaining the client on bed rest is not an appropriate action, as it can increase the risk of thromboembolism, infection, or atelectasis after surgery. The nurse should encourage early ambulation and exercise as tolerated by the client.
Choice B reason: Decreasing the client's fluid intake is not an appropriate action, as it can cause dehydration, constipation, or impaired wound healing after surgery. The nurse should encourage adequate hydration and nutrition to promote recovery and drainage.
Choice C reason: Applying cold compresses to the site is not an appropriate action, as it can cause vasoconstriction, inflammation, or pain at the site. The nurse should apply warm compresses to the site to facilitate drainage and reduce swelling.
Choice D reason: Placing the right leg in a dependent position is an appropriate action, as it can promote gravity-assisted drainage from the site and prevent fluid accumulation or infection. The nurse should place the drain below the level of the wound and secure it to prevent dislodgment or tension.
Correct Answer is C
Explanation
Choice A reason: Discouraging reminiscing about the past is not a helpful strategy for a client who has dementia and confusion. Reminiscing can stimulate memory, enhance mood, and promote social interaction.
Choice B reason: Asking open-ended questions that encourage the client to express their feelings is not appropriate for a client who has dementia and confusion. Open-ended questions can increase frustration and anxiety for the client who may have difficulty finding words or recalling events. The nurse should use simple, direct, and closed-ended questions instead.
Choice C reason: Using holiday decorations to provide orientation to the time of the year is a beneficial action for a client who has dementia and confusion. Holiday decorations can help the client recognize familiar cues and reduce disorientation.
Choice D reason: Encouraging multiple family members to visit the client at the same time is not advisable for a client who has dementia and confusion. Multiple visitors can overwhelm and agitate the client who may have trouble recognizing faces or voices. The nurse should limit the number of visitors and ensure they are calm and supportive.
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