A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?
Weight loss of 1 kg (2.2 lb) in the past 24 hr
Pale, clammy skin
Fatigue when ambulating 152 m (500 ft)
Productive cough with pink, frothy sputum
The Correct Answer is D
A productive cough with pink, frothy sputum is indicative of pulmonary edema, which is a serious manifestation of left-sided heart failure.
It suggests fluid accumulation in the lungs, impairing gas exchange and oxygenation.
Prompt notification of the provider is crucial for appropriate intervention and management of the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Whenever a medication error occurs, it should be documented in an incident report. The purpose of the incident report is to document the details of the event, including what happened, why it happened, and what was done to prevent it from happening again. Incident reports are not part of the client's medical record and are not used for disciplinary action. They are used for quality improvement and risk management purposes.
The nursing care plan is a document that outlines the client's nursing care needs and interventions. It is not the appropriate place to document a medication error.
The controlled substance inventory record is used to document the administration and dispensing of controlled substances. It is not the appropriate place to document a medication error.
The provider's progress notes document the provider's assessment, diagnosis, and treatment plan for the client. They are not the appropriate place to document a medication error.


Correct Answer is A
Explanation
The normal range for potassium levels is generally between 3.5 to 5.0 mEq/L. A potassium level of 3.5 mEq/L falls within the lower end of the normal range, suggesting that the client's potassium levels are relatively stable. This finding alone does not indicate the overall effectiveness of the behavioral plan.
The normal range for sodium levels is typically between 135 to 145 mEq/L. A sodium level of 130 mEq/L falls below the normal range and indicates hyponatremia (low sodium levels). Hyponatremia can be a cause for concern, and it suggests that the behavioral management plan may need further attention or adjustments.
The normal range for hemoglobin (Hgb) levels varies depending on factors such as age and gender. However, in general, a Hgb level of 10 g/dL falls below the normal range and indicates anemia. Anemia is a common complication in individuals with anorexia nervosa and can result from inadequate nutrient intake. This finding suggests that the behavioral plan may need further evaluation and adjustment to address the client's nutritional needs.
Body Mass Index (BMI) is a measure that relates weight and height. A BMI of 14.5 indicates severe underweight and is well below the normal range. This finding suggests that the client's nutritional status is still significantly compromised, and the behavioral management plan may require further attention to support weight restoration and overall recovery.

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