The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

Crackles in bilateral lower lobes.

Heart rate of 92 beats/minute.

Blood pressure of 138/86 mm Hg.

Peripheral edema 1+ in ankles.

Answer and Explanation

The Correct Answer is A

Choice A reason: Crackles in bilateral lower lobes indicate pulmonary edema in heart failure, where reduced cardiac output causes fluid backup into alveoli, impairing gas exchange and causing dyspnea. This life-threatening emergency requires immediate diuretics or oxygen to reduce preload, preventing respiratory failure or hypoxia, prioritizing intervention.

Choice B reason: A heart rate of 92 beats/minute is normal and not urgent in heart failure, where dyspnea and fatigue suggest fluid overload. Crackles indicate pulmonary edema, a critical issue compromising oxygenation, necessitating immediate action to restore respiratory function, making heart rate less concerning.

Choice C reason: Blood pressure of 138/86 mm Hg is mildly elevated but not critical in heart failure. Crackles signal pulmonary edema, where fluid in alveoli impairs gas exchange, risking hypoxia. This requires urgent intervention like furosemide, as respiratory compromise is more immediate than managing stable blood pressure.

Choice D reason: Peripheral edema 1+ indicates fluid retention in heart failure but is less urgent than crackles, which signify pulmonary edema. Alveolar fluid causes dyspnea and hypoxia, requiring immediate diuretics. Edema is chronic, making respiratory assessment and intervention the priority to prevent acute respiratory failure.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Difficulty swallowing secretions in croup signals severe airway narrowing from subglottic edema, often parainfluenza-induced. This risks stridor and obstruction, leading to respiratory distress or hypoxia. It requires urgent evaluation for corticosteroids or epinephrine, prioritizing airway patency over less critical symptoms, preventing life-threatening complications.

Choice B reason: Fever of 101.0°F (38.3°C) is common in croup, indicating viral infection, but less urgent than swallowing difficulty, which suggests critical airway compromise. Fever is managed with antipyretics, but severe edema risking obstruction necessitates immediate intervention, making this a lower priority concern.

Choice C reason: Crying when nursing may reflect croup’s sore throat or breathing difficulty but is less specific than swallowing difficulty, indicating severe airway narrowing. Crying does not directly signal life-threatening obstruction, making it less urgent than symptoms of significant subglottic inflammation requiring medical attention.

Choice D reason: Barking cough, worse at night, is typical in croup from subglottic inflammation but managed with supportive care or steroids. Difficulty swallowing secretions indicates severe airway compromise, risking obstruction, requiring urgent intervention over a cough, which is an expected, less critical symptom.

A. “Your PCA pump has just been discontinued, and you need to wait at least one hour before leaving the unit.” B. “As long as you go to the smoking area in a wheelchair, it will be all right for you to go smoke.” C. “You may smoke in your room if you keep the door closed and open a window.” D. “Smoking is hazardous to your health, and since you just had surgery, it would be best for you to avoid smoking.”

Correct Answer is D

Explanation

Choice A reason: Delaying smoking for one hour is arbitrary and does not address smoking’s risks post-surgery. Nicotine causes vasoconstriction, reducing wound perfusion, and carbon monoxide impairs oxygen delivery, delaying healing. Advising against smoking mitigates these risks, promoting recovery, making this response less effective than cessation advice.

Choice B reason: Allowing smoking in a wheelchair ignores postoperative risks. Nicotine’s vasoconstriction reduces tissue oxygenation, and carbon monoxide lowers hemoglobin’s capacity, impairing healing. This increases infection or thrombosis risk. Advising against smoking addresses these physiological harms, prioritizing wound recovery over facilitating smoking, which is detrimental.

Choice C reason: Smoking in the room violates hospital safety and exposes others to secondhand smoke. Nicotine and carbon monoxide reduce tissue perfusion and oxygen delivery, delaying postoperative healing. Advising against smoking prevents these complications, ensuring better recovery, making this response unsafe and inappropriate for surgical patients.

Choice D reason: Advising against smoking is critical, as nicotine causes vasoconstriction, reducing blood flow to surgical sites, and carbon monoxide impairs oxygen delivery, delaying healing. These increase infection and thrombosis risks post-surgery. This response promotes optimal recovery, addressing physiological needs for wound healing in the critical 24-hour period.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

Correct Answer is A

Explanation

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

Correct Answer is D

Explanation

A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic-clonic seizure. The mother is hysterical and is trying to hold the child down. What action(s) should the nurse take? (Select all that apply)

The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

The nurse is caring for a client with urolithiasis who reports severe flank and abdominal pain. Which action should the nurse implement?

The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?

Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?

The nurse is teaching a client with newly diagnosed glaucoma about the condition. Which statement by the client indicates a need for further teaching?

An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?