The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?

Lung sounds

Facial swelling

Level of anxiety

Intake and output

Answer and Explanation

The Correct Answer is A

In a patient with acute decompensated heart failure (ADHF), the priority nursing assessment is to auscultate lung sounds. ADHF is characterized by the sudden worsening of heart failure symptoms, which may include pulmonary congestion and fluid accumulation in the lungs. Assessing lung sounds helps to identify signs of pulmonary edema, which is a serious complication of ADHF.

The nurse should listen for crackles or rales, which are abnormal lung sounds caused by the presence of fluid in the alveoli. These findings suggest that the patient is experiencing fluid overload and inadequate gas exchange in the lungs. Prompt recognition of pulmonary edema allows for early intervention, such as administering diuretics or other medications, to relieve fluid overload and improve respiratory function.

While the other options (B) Facial swelling, (C) Level of anxiety, and (D) Intake and output, are important assessments in a patient with heart failure, they are not the priority in a patient with manifestations of acute decompensated heart failure. The priority is to assess for signs of respiratory

distress and pulmonary congestion, as these can quickly lead to respiratory failure and life threatening complications.

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Correct Answer is D

Explanation

ST-segment elevation on an electrocardiogram (ECG) is a critical finding and should be reported rapidly to the health care provider. It is a hallmark ECG change seen in myocardial infarction (heart attack). When there is myocardial ischemia or injury (such as in a heart attack), the ST segment

elevates above the baseline in the affected leads of the ECG. This elevation indicates that there is an ongoing loss of oxygen and blood supply to a part of the heart muscle.

ST-segment elevation is a medical emergency because it suggests acute coronary syndrome (ACS), which can rapidly progress to a myocardial infarction if not promptly treated. Immediate intervention is needed to restore blood flow to the affected coronary artery and prevent further damage to the heart muscle.

The other options listed (A) First-degree atrioventricular block, (B) Inverted P wave, and (C) Sinus tachycardia, while significant in some situations, do not have the same urgency as ST-segment elevation in the context of chest pain. They may require medical attention, but they do not typically indicate an acute myocardial infarction or an immediate life-threatening condition. ST-segment elevation is a critical finding that requires rapid intervention to preserve heart muscle function and prevent complications.

A. Delegated to the health care provider B. Discussed along with other physical activities C. Avoided because it is embarrassing to the patient D. Accomplished by providing the patient with written material

Correct Answer is B

Explanation

Resumption of sexual activity after a myocardial infarction (MI) is an important topic to address as part of the overall recovery and rehabilitation process. It should be discussed along with other physical activities during the patient's recovery. The nurse should initiate the discussion in a supportive and non-judgmental manner, addressing the patient's concerns, fears, and questions about sexual activity after an MI.

Sexual activity is a normal part of life, and patients may have concerns about the safety and appropriateness of engaging in sexual activity after a significant cardiac event like an MI. Discussing it along with other physical activities helps normalize the topic and allows the nurse to provide accurate information, address any misconceptions, and offer guidance on when and how to resume sexual activity safely. Patients should be encouraged to have an open dialogue with their healthcare provider about their concerns and any specific questions they may have related to resuming sexual activity.

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The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which electrocardiographic (ECG) change by a client with chest pain is most important for the nurse to report rapidly to the health care provider?

Correct Answer is D

Explanation

The nurse is providing teaching to a patient recovering from a myocardial infarction (MI). How should resumption of sexual activity be discussed?

Correct Answer is B

Explanation

A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

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A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

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The nurse recalls that which type of drug therapy is used to treat volume overload in patients with acute decompensated heart failure (ADHF)?

The nurse teaches a student nurse about diagnostic studies used for acute coronary syndrome. Which statement made by the student nurse indicates effective learning?

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)