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: This is incorrect because stool being a dark green color is not a finding that the nurse should report to the provider. Stool from an ileostomy can be dark green, brown, or yellow depending on the diet and fluid intake of the client.
Choice B: This is incorrect because stoma being a cherry red color is not a finding that the nurse should report to the provider. Stoma from an ileostomy should be moist and pink or red, indicating adequate blood supply and healing.
Choice C: This is incorrect because stool containing scant red blood is not a finding that the nurse should report to the provider. Stool from an ileostomy can contain small amounts of blood due to irritation or inflammation of the bowel mucosa.
Choice D: This is correct because stoma retracting into the abdominal wall is a finding that the nurse should report to the provider. Stoma from an ileostomy should protrude slightly above the skin level, allowing for proper drainage and appliance fitting. Stoma retraction can indicate ischemia, obstruction, or peritonitis.
Correct Answer is A
Explanation
Choice A: This is correct because placing electrical cords against the wall can prevent tripping and falling, which can cause injury or dislocation of the hip prosthesis. The nurse should instruct the client to remove any clutter or obstacles from the floor and use assistive devices such as a walker or cane.
Choice B: This is incorrect because placing a throw rug next to the bathtub can increase the risk of slipping and falling, especially when the floor is wet. The nurse should instruct the client to avoid using throw rugs or mats and install grab bars and non-skid mats in the bathroom.
Choice C: This is incorrect because keeping pot handles turned toward the edge of the stove can cause burns or spills, which can also lead to falls or infections. The nurse should instruct the client to turn pot handles inward or use the back burners of the stove.
Choice D: This is incorrect because storing extra blankets in a box on the steps can obstruct the access to the stairs and pose a hazard for falling. The nurse should instruct the client to store extra blankets in a closet or drawer and use handrails when using the stairs.
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