The emergency room nurse is assessing a client with jugular venous distention, ascites, shortness of breath, and a 3-pound weight gain in the past 24 hours. Which of the following would the nurse anticipate being ordered?
Pulmonary Function Test
Alpha-1 Antitrypsin
Brain Natriuretic Peptide
Doppler Ultrasound
The Correct Answer is C
A. A pulmonary function test is used to assess lung diseases like COPD or asthma. It is not the primary diagnostic test for fluid overload and heart failure.
B. Alpha-1 antitrypsin deficiency is associated with early-onset COPD, but it does not relate to symptoms of fluid retention and heart failure as described in the question.
C. Brain Natriuretic Peptide (BNP) is correct. BNP is released when the ventricles stretch due to fluid overload, making it a key diagnostic marker for heart failure. Elevated BNP levels indicate increased cardiac filling pressures and volume overload, which match the client’s symptoms.
D. A Doppler ultrasound is useful for detecting deep vein thrombosis (DVT) or vascular issues, but it does not assess systemic fluid retention and heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Taking 4 nitroglycerin tablets is incorrect. The maximum dose is 3 tablets, taken 5 minutes apart. If chest pain persists after the third dose, the client should seek emergency help.
B. Calling 911 after only one dose is incorrect. The correct protocol is to take up to three doses before seeking emergency assistance unless symptoms worsen rapidly.
C. Calling 911 immediately before taking nitroglycerin is incorrect. The client should attempt to relieve the chest pain with nitroglycerin before calling for emergency help.
D. Calling 911 if pain persists after taking 3 nitroglycerin tablets 5 minutes apart is correct. Persistent chest pain despite nitroglycerin use suggests a possible myocardial infarction (MI), requiring immediate medical intervention.
Correct Answer is C
Explanation
A. Warfarin is commonly prescribed for long-term anticoagulation to prevent future clot formation. This statement is correct and does not require further teaching.
B. A Heparin infusion does not dissolve existing clots but prevents them from enlarging and new clots from forming, making this statement accurate.
C. The purpose of the Inferior Vena Cava (IVC) filter is to trap emboli from deep vein thrombosis (DVT) before they reach the lungs, not to prevent DVT formation. This statement is incorrect and requires further teaching.
D. An embolectomy is a surgical procedure to remove a pulmonary embolism, making this statement correct.
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