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 B
Explanation
Choice A: This is incorrect because maintaining the client on bed rest can increase the risk of complications such as pneumonia, thromboembolism, or pressure ulcers. The nurse should encourage early ambulation and frequent position changes to promote healing and prevent complications.
Choice B: This is correct because repositioning the client can help relieve pressure and discomfort from the incision site. The nurse should assist the client to change positions every 2 hours and use pillows or splints to support the incision.
Choice C: This is incorrect because applying a warm, moist compress to the incision area can interfere with wound healing and increase the risk of infection. The nurse should keep the incision site clean and dry and follow the provider's orders for dressing changes.
Choice D: This is incorrect because administering an additional dose of pain medication is not necessary when the client reports a pain level of 2 on a scale of 0 to 10. The nurse should monitor the client's pain level and administer pain medication as prescribed and as needed.
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