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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Inserting a small bore tube for enteral feedings is inappropriate for acute GERD exacerbation, as feeding increases gastric volume, worsening reflux by raising pressure and acid exposure. Proton pump inhibitors (PPIs) reduce acid production, alleviating mucosal irritation, addressing GERD’s pathophysiology more effectively than nutritional interventions.

Choice B reason: Intravenous PPIs (e.g., pantoprazole) are standard for severe GERD, inhibiting H+/K+-ATPase in parietal cells, reducing acid secretion. This promotes esophageal healing when oral famotidine fails. IV delivery ensures rapid onset, critical for controlling worsening symptoms, preventing complications like esophagitis or Barrett’s esophagus in acute settings.

Choice C reason: Total parenteral nutrition (TPN) bypasses the gut, used for conditions like bowel obstruction, not GERD, which involves acid reflux from sphincter dysfunction. TPN does not address acid production. PPIs target the pathophysiological cause, reducing esophageal acid exposure, making TPN irrelevant for GERD management.

Choice D reason: A nasogastric tube with suction removes gastric contents but does not treat GERD’s acid reflux, caused by lower esophageal sphincter dysfunction. It risks aspiration and is temporary. PPIs effectively reduce acid, preventing esophageal damage, making them the preferred treatment for severe GERD exacerbation.

A. Place the client in a right lateral side-lying position and elevate the head of the bed. B. Compress the bulb with the tab open and then reinsert the tab into its opening. C. Irrigate the drain tubing with 1 mL of NS, then close the opening with its tab. D. Reinforce the incisional dressings and assess behind the neck for drainage.

Correct Answer is B

Explanation

Choice A reason: Positioning right lateral with head elevation may shift fluid but does not restore drain suction. Compressing the bulb creates negative pressure, promoting drainage. Positioning is less effective, per surgical drain management and postoperative care standards in nursing practice.

Choice B reason: Compressing the bulb with the tab open, then reinserting it, restores negative pressure, enhancing drainage in the surgical drain. This ensures fluid removal, preventing hematoma or infection, per evidence-based surgical drain management and postoperative care protocols in nursing practice.

Choice C reason: Irrigating the drain with saline risks infection and is not standard for low drainage. Compressing the bulb restores suction, promoting drainage safely. Irrigation is inappropriate, per surgical drain management and infection control standards in postoperative nursing care.

Choice D reason: Reinforcing dressings and assessing drainage addresses symptoms, not the cause of low drainage. Compressing the bulb restores suction, increasing drainage effectively. Dressings are secondary, per surgical drain management and postoperative wound care protocols in nursing practice.

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

A client with gastroesophageal reflux disorder (GERD), who has been self-medicating with famotidine for the past week, is admitted to the acute care center because the symptoms have worsened. The nurse should anticipate which treatment?

Correct Answer is B

Explanation

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

Correct Answer is B

Explanation

A client with chronic kidney disease (CKD) is prescribed a low-potassium diet. Which food choice indicates to the nurse that the client understands the dietary restrictions?

After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

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)

Following a total thyroidectomy, the nurse plans to observe a client for complications. Which finding indicates that the client has developed a complication?

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

The nurse orients a client with depression to a new room on the mental health unit. The client states, “It seems strange that I don’t have a television (TV) in my room.” Which statement is best for the nurse to provide?

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?