The nurse is reviewing the patient’s recent symptoms and lab results. Which of the following symptoms or findings suggest worsening heart failure? (Select all that apply)

Oxygen saturation of 92% on room air

Bilateral pulmonary congestion on chest x-ray

Recent 5-lb weight gain

BUN of 28 mg/dL

Potassium of 4.9 mEq/L

Answer and Explanation

Correct Answer : B,C

Choice A reason: Oxygen saturation of 92% is low-normal (95-100%), not specific to worsening heart failure acutely. It may reflect chronic lung issues or mild hypoxia, but alone, it’s not a definitive sign of decompensation.

Choice B reason: Bilateral pulmonary congestion on x-ray shows fluid in alveoli from left heart failure, impairing gas exchange. It’s a classic sign of worsening, as rising pressure backs fluid into lungs, causing dyspnea.

Choice C reason: A 5-lb weight gain over days indicates fluid retention, a hallmark of worsening heart failure. It reflects sodium and water buildup from reduced cardiac output, directly correlating with symptom exacerbation.

Choice D reason: BUN of 28 mg/dL (normal 7-20 mg/dL) suggests mild renal stress, possibly from diuretics. It’s not specific to worsening heart failure without symptoms like dyspnea, as it may reflect dehydration instead.

Choice E reason: Potassium of 4.9 mEq/L is normal (3.5-5.0 mEq/L), not indicating worsening heart failure. It may rise with ACE inhibitors, but this value alone doesn’t signal acute decompensation or symptom progression.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason: Speech therapists assess swallowing in tracheostomy patients, as the tube alters airway dynamics. Collaboration ensures safe oral intake, preventing aspiration, a critical task aligning with their expertise in dysphagia management.

Choice B reason: Physical therapists plan mobility in tracheostomy care, enhancing strength and preventing atrophy. Collaboration promotes early activity, improving respiratory muscle function and recovery, tailored to the patient’s physical capacity.

Choice C reason: Respiratory therapists provide tracheostomy care, like suctioning and cuff management, maintaining airway patency. Collaboration ensures proper technique, reducing infection or obstruction risks, a core responsibility in respiratory support.

Choice D reason: Dietitians recommend nutrition plans for tracheostomy patients, addressing caloric and swallowing needs. Collaboration optimizes healing and energy, adjusting diets (e.g., thickened liquids) to support recovery and prevent complications.

A. I get short of breath when I climb a lot of stairs. B. My fingers hurt when I go outside in cold weather. C. My legs cramp when I walk more than a block. D. When I stand too long, my feet start to swell.

Correct Answer is C

Explanation

Choice A reason: Shortness of breath on stairs suggests cardiopulmonary issues, not intermittent claudication. Claudication is leg pain from arterial insufficiency during activity, not dyspnea, which reflects lung or heart strain.

Choice B reason: Finger pain in cold weather points to Raynaud’s or vasospasm, not claudication. Intermittent claudication affects lower limbs from arterial occlusion, not upper extremities or temperature-related vasomotor changes.

Choice C reason: Leg cramping after walking a block is classic intermittent claudication, from reduced blood flow in peripheral artery disease. Pain with activity, relieved by rest, matches its ischemic pathophysiology perfectly.

Choice D reason: Foot swelling from standing suggests venous stasis or edema, not claudication. Claudication involves arterial insufficiency causing pain with exertion, not fluid accumulation from prolonged static posture.

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The nurse is reviewing the patient’s recent symptoms and lab results. Which of the following symptoms or findings suggest worsening heart failure? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Nursing management of patients with tracheostomies includes collaboration with other healthcare team members. Match the Health care team member with the correct collaborative task.

Correct Answer is ["A","B","C","D"]

Explanation

Which patient statement supports a history of intermittent claudication?

Correct Answer is C

Explanation

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