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.

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Correct Answer is C

Explanation

Choice A reason: Denying muscle spasms is normal and not a complication. Muscle twitching indicates hypocalcemia, a thyroidectomy risk due to parathyroid damage. Absence of spasms is reassuring, per postoperative complication monitoring and endocrine surgical care standards in nursing.

Choice B reason: Back and joint pain are nonspecific and not typical thyroidectomy complications. Muscle twitching suggests hypocalcemia, a critical issue post-thyroidectomy. Pain requires assessment but is less urgent, per postoperative monitoring and complication management protocols in surgical nursing.

Choice C reason: Muscle twitching in hands and feet indicates hypocalcemia, a serious complication from parathyroid gland damage during thyroidectomy. This requires immediate calcium replacement to prevent tetany, per postoperative complication monitoring and endocrine surgical care protocols in nursing practice.

Choice D reason: Diaphoresis without headache is nonspecific and not a primary thyroidectomy complication. Muscle twitching signals hypocalcemia, needing urgent intervention. Diaphoresis requires monitoring but is less critical, per postoperative assessment and complication management standards in surgical nursing.

A. Administer a PRN narcotic. B. Ask the husband to step out. C. Have delivery table set up. D. Notify rapid response team.

Correct Answer is C

Explanation

Choice A reason: Administering a PRN narcotic at 9 cm dilation is inappropriate, as labor is in transition, nearing delivery. Narcotics risk fetal respiratory depression, crossing the placenta, especially with a stable fetal heart rate (120 beats/minute). Preparing for imminent delivery is critical, prioritizing a safe birth environment over pain relief.

Choice B reason: Asking the husband to leave does not address the client’s advanced labor (9 cm, 100% effaced, frequent contractions). His presence may provide support, and removal could increase distress. Setting up the delivery table is urgent, as birth is imminent, ensuring a sterile, safe environment for delivery.

Choice C reason: At 9 cm dilation, 100% effacement, and contractions every 2 minutes, the client is in transition, with delivery imminent. Setting up the delivery table ensures readiness for vaginal birth, providing a sterile field and equipment, addressing the physiological progression of labor for safe delivery of the newborn.

Choice D reason: Notifying the rapid response team is unnecessary, as the fetal heart rate (120 beats/minute) is normal (110–160), and screaming reflects labor pain. Delivery is imminent, making table setup the priority to facilitate safe birth, avoiding escalation to emergency response for a normal labor progression.

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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?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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