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 A reason: Eliminating egg whites from the diet is not necessary, as they are a good source of protein and do not contain any fat or cholesterol. The client should limit or avoid egg yolks, which are high in cholesterol and saturated fat.
Choice B reason: Using coconut oil when preparing food is not advisable, as it is a source of saturated fat that can raise blood cholesterol levels and increase the risk of atherosclerosis and heart disease. The client should use unsaturated fats, such as olive oil or canola oil, which can lower blood cholesterol levels and improve heart health.
Choice C reason: Eating fish three times a week is a good practice, as fish are rich in omega-3 fatty acids that can reduce inflammation, lower blood pressure, and prevent blood clots that can cause heart attacks or strokes. The client should choose oily fish, such as salmon, tuna, or mackerel, which have higher amounts of omega-3 fatty acids.
Choice D reason: Including 2 percent milk in the diet is not recommended, as it contains more fat and calories than skim or 1 percent milk. The client should choose low-fat or fat-free dairy products, such as yogurt, cheese, or milk, which can provide calcium and protein without excess fat.
Correct Answer is A
Explanation
The correct answer is A:
Choice A reason:
Replace the unit when the drainage chamber is full. This ensures continuous, effective drainage. A full chamber cannot collect more fluid, risking system compromise and patient safety.
Choice B reason:
Pinning the tubing to the bed sheets is incorrect because it can cause kinks in the tubing, leading to obstruction of drainage and potential complications.
Choice C reason:
Monitoring for at least 150 mL of drainage every hour is not a standard practice. Normal chest tube drainage is variable; excessive drainage, such as 150 mL/hour, could indicate a serious condition like hemorrhage.
Choice D reason:
Clamping the tube routinely for 30 minutes every 8 hours is not recommended. Clamping may be done during tube removal or to check for air leaks but doing so routinely can lead to tension pneumothorax.
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