Which finding is the most concerning and should prompt immediate action by the nurse?

Potassium level of 4.8 mEq/L

Episodes of dizziness and blurred vision

Chest x-ray showing mild left ventricular hypertrophy

Blood pressure of 168/98 mmHg

Answer and Explanation

The Correct Answer is B

Choice A reason: Potassium of 4.8 mEq/L is within normal range (3.5-5.0 mEq/L), posing no immediate threat. Hyperkalemia risks arrhythmias, but this level doesn’t warrant urgent action, as it’s stable and unlikely to disrupt cardiac function acutely.

Choice B reason: Dizziness and blurred vision suggest cerebral hypoperfusion or stroke, potentially from hypertension or embolism. These neurologic symptoms demand immediate action to assess and treat, as they indicate acute risk to brain function or life.

Choice C reason: Mild left ventricular hypertrophy on x-ray reflects chronic hypertension adaptation, not an acute emergency. It’s a stable finding requiring management, but it doesn’t necessitate immediate intervention compared to symptomatic neurologic changes.

Choice D reason: Blood pressure of 168/98 mmHg is elevated (stage 2 hypertension), risking long-term damage. Without acute symptoms, it’s less urgent than dizziness and vision changes, which signal immediate compromise needing rapid response.

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Correct Answer is C

Explanation

Choice A reason: A cardiac diet (low sodium, low fat) supports blood pressure control long-term by reducing vascular strain. However, it’s less immediate than addressing adherence, as dietary change alone won’t correct current medication misuse driving the elevation.

Choice B reason: Cardiac assessment identifies complications like hypertrophy, useful for monitoring. It’s reactive, not proactive, and doesn’t address the root issue of inconsistent adherence, which directly impacts blood pressure control and outcomes now.

Choice C reason: Medication education tackles adherence, the primary cause of uncontrolled hypertension here. Teaching proper use ensures therapeutic levels, reducing pressure via vasodilation or fluid control, directly improving outcomes with evidence-based efficacy.

A. Ask the Health Care Provider to order a sweat chloride test. B. Coordinate with the dietitian to place the patient on a low-sodium diet. C. Coordinate with respiratory therapy to perform chest physiotherapy D. Coordinate with the case manager to arrange for a hospice nurse visit.

Correct Answer is C

Explanation

Choice A reason: Sweat chloride tests diagnose CF, not manage dyspnea in a known patient. It’s irrelevant here, as the focus is treating acute respiratory symptoms, not reconfirming an established diagnosis in this scenario.

Choice B reason: Low-sodium diets aren’t indicated for CF; patients need high salt due to losses. Dyspnea stems from mucus obstruction, not fluid, so this intervention contradicts CF physiology and symptom management.

Choice C reason: Chest physiotherapy clears mucus in CF, improving airflow and reducing dyspnea. It targets the primary cause—thick secretions—enhancing lung function, a standard intervention coordinated with respiratory therapy for acute exacerbations.

Choice D reason: Hospice is premature for dyspnea in CF without end-stage decline. It’s inappropriate now, as active interventions like physiotherapy address reversible symptoms, prioritizing treatment over palliative care planning.

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Which finding is the most concerning and should prompt immediate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Explanation

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Which finding is the most concerning and should prompt immediate action by the nurse?