The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to:

prepare to place the client in a single room.

ask the client if they wish to speak to a spiritual advisor.

explore the possibility of suicidal thoughts with the client.

explain to the client that they will not die for a long time.

Answer and Explanation

The Correct Answer is C

A.   While privacy may be important for a patient who is emotionally distressed, the priority is addressing
the client’s emotional state, not the physical environment.
B.   This might be helpful later, but the priority is to explore the patient's feelings and concerns regarding their condition first. Immediate emotional support is more important at this stage.
C.   When a patient expresses feelings of hopelessness, as in this case, the nurse must assess for potential suicidal ideation. This is a priority to ensure patient safety and to provide necessary psychological support or intervention.
D.   While reassurance is important, providing false or unrealistic expectations can lead to further disappointment. The nurse should focus on addressing emotional distress and offering realistic support rather than giving definitive assurances.

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Correct Answer is B

Explanation

A. A low hemoglobin level indicates anemia, not heart failure. While anemia can exacerbate heart failure, it is not the primary indicator.
B. BNP is a biomarker that is elevated in response to heart failure. A level above 100 pg/mL is suggestive of heart failure, and 410 pg/mL indicates significant heart stress and likely acute heart failure.
C. A low sodium level (hyponatremia) can occur in heart failure, but it is not specific enough to confirm the diagnosis. BNP is a more direct indicator of heart failure.
D. This is a normal fibrinogen level and does not indicate heart failure. Fibrinogen is more associated with clotting disorders.

A. Heart rate 100 beats per minute B. + 3 peripheral edema C. Respiratory rate of 24 at rest D. Alert and oriented X 3

Correct Answer is D

Explanation

A. A heart rate of 100 beats per minute is considered tachycardia (a heart rate above 100 bpm). This is not an indicator of improvement in heart failure, as it suggests the heart is working harder than usual. Chronic heart failure can lead to compensatory mechanisms such as tachycardia, but it’s typically not a sign of improvement.
B. Peripheral edema (swelling in the legs, ankles, or feet) is a common symptom of heart failure, resulting from fluid buildup due to poor cardiac output. A rating of +3 edema indicates moderate to severe swelling, which suggests fluid retention and poor circulation. This is a sign of worsening or poorly controlled heart failure, not improvement.
C. A respiratory rate of 24 breaths per minute is slightly elevated, as the normal resting respiratory rate for adults is typically between 12 to 20 breaths per minute. A higher respiratory rate can be a sign of respiratory distress or compensatory breathing due to insufficient oxygenation or fluid buildup in the lungs (pulmonary edema), which are both symptoms of heart failure exacerbation.
D. Being alert and oriented X 3 means the client is aware of time, place, and person, indicating no signs of confusion or cognitive impairment. In the context of chronic heart failure, mental status changes (like confusion or disorientation) can occur due to decreased cerebral perfusion, low oxygen levels, or medications (such as diuretics or digitalis.

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The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with acute heart failure on the telemetry unit. Which laboratory result does the nurse know is most indicative of this diagnosis?

Correct Answer is B

Explanation

Which clinical manifestation would the nurse use to best indicate that the status of an elderly client's chronic heart failure condition is Improving?

Correct Answer is D

Explanation

The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The nurse recognizes that which laboratory test order set will guide the provider to a diagnosis of DIC?

The nurse is caring for a client who is to have an autologous transfusion of packed red blood cells. The nurse recognizes the client requires additional teaching when they state:

The nurse is providing discharge instructions to a client who has had a permanent pacemaker inserted. The information in the chart indicates that the device is a DDD. What will the nurse explain about this pacemaker?

A patient is prescribed 250 mL of packed red blood cells to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

The nurse administers atropine 0.5 mg IV to a client. Which action should be performed after the client has received this medication?

The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

The nurse notes that the client's rhythm strip indicates a PR-interval of 0.28 seconds. What is the nurse's analysis of this problem?