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 D

Explanation

A. This would be concerning, but it is not the correct choice. If a pacemaker is functioning abnormally, it would require an assessment and troubleshooting, not simply a routine rhythm.
B. This is typical for biventricular pacemakers used in heart failure patients, but it would not apply to a patient with a standard pacemaker unless specified. A recent pacemaker placement does not necessarily indicate biventricular pacing.
C. This is correct if only the atrium is paced; however, in the case of a typical pacemaker like DDD (dual- chamber pacemaker), both the atrium and ventricle are paced.
D. This is correct for dual-chamber pacemakers (like DDD), which pace both the atrium and the ventricle to coordinate the heart's rhythm.

A. There is an increased risk for cardiac dysrhythmias B. There is dilutional hyponatremia and fluid retention C. There is an imbalance in the sodium-potassium pump D. The client is in acute renal failure related to heart failure

Correct Answer is B

Explanation

A. Increased risk for cardiac dysrhythmias: While hyponatremia can sometimes contribute to cardiac dysrhythmias, it's not the primary concern in this case. The main issue is fluid overload.
B. Hyponatremia, or low sodium levels, is often associated with heart failure. In this condition, the heart's reduced pumping ability leads to fluid retention, which dilutes the sodium concentration in the blood.
C. Imbalance in the sodium-potassium pump: While this can contribute to electrolyte imbalances, it's not the direct cause of hyponatremia in heart failure.
D. Acute renal failure: While heart failure can lead to acute kidney injury, hyponatremia is primarily a result of fluid overload rather than kidney dysfunction.

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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 assessing the client with a recent pacemaker placement. The client's monitor is displaying what type of rhythm?

Correct Answer is D

Explanation

The nurse is reviewing the laboratory values for the client diagnosed with heart failure and notes the sodium level is 128 mEq/L (normal 135-145mEq/L). How should the nurse interpret this finding?

Correct Answer is B

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 evaluating the outcomes for a client diagnosed with disseminated intravascular coagulation (DIC). Which laboratory value reflects a positive outcome?

The nurse is caring for a client diagnosed with disseminated intravascular coagulation (DIC). When completing an assessment for decreased perfusion from clotting, the nurse would observe for which manifestation?

The nurse is caring for a client who received a transfusion of Fresh Frozen Plasma (FFP) for an acute GI bleed related to accidental wantarin overdose. Which laboratory result would indicate the need for an additional unit of Fresh Frozen Plasma (FFP) to correct the problem caused by the overdose?

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

Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

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?