The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
A client with left-sided heart failure on oxygen via nasal cannula
A client with syncope who is being discharged today
A client scheduled for a cardiac ultrasound this morning
A client with controlled atrial fibrillation with a heart rate of 82
The Correct Answer is A
A. A client with left-sided heart failure on oxygen via nasal cannula: This client is at risk for respiratory distress due to pulmonary congestion. Immediate assessment is needed to ensure oxygenation and manage potential deterioration.
B. A client with syncope who is being discharged today: This client is stable if being discharged, so assessment can be delayed.
C. A client scheduled for a cardiac ultrasound this morning: This is a non-urgent diagnostic procedure and does not take priority.
D. A client with controlled atrial fibrillation with a heart rate of 82: Controlled atrial fibrillation indicates stability, so this client can be assessed later.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "It is an amino acid which reflects damage to the endothelial lining of arteries." BNP is not related to endothelial damage.
B. "It is a substance composed of free fatty acids reflective of atherosclerosis." BNP is not composed of free fatty acids, and it does not reflect atherosclerosis.
C. "It is a reliable indicator of the presence of heart failure." BNP is a hormone released by the heart in response to increased pressure and volume. Elevated levels of BNP are commonly used as a diagnostic marker for heart failure, especially during exacerbations or decompensation.
D. "It is a protein produced by the liver in response to systemic inflammation." BNP is produced by the heart, not the liver.
Correct Answer is A
Explanation
A. Hypokalemia: U waves are often seen on an electrocardiogram in clients with hypokalemia. They represent delayed repolarization of the Purkinje fibers due to low potassium levels.
B. Hypercalcemia: Hypercalcemia affects the QT interval, typically shortening it, but it does not cause U waves.
C. Hyponatremia: Electrocardiographic changes are not commonly associated with hyponatremia.
D. Hyperkalemia: Hyperkalemia causes peaked T waves, prolonged PR intervals, and wide QRS complexes, not U waves.
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