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The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis?
- A. Basic metabolic panel (BMP)
- B. B-type natriuretic peptide (BNP)
- C. Lipid profile
- D. Troponin
Correct Answer: B
Rationale: BNP is a specific biomarker elevated in heart failure, reflecting ventricular stress and fluid overload.
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Which of the following should the nurse do for a client reporting chest pain radiating to the arm? Select all that apply.
- A. Obtain an electrocardiogram (ECG)
- B. Prepare the client for cardioversion
- C. Establish intravenous (IV) access
- D. Insert an indwelling urinary catheter
- E. Administer prescribed nitroglycerin
Correct Answer: A,C,E
Rationale: ECG is critical to diagnose the cause of chest pain. B: Incorrect - Cardioversion is for specific arrhythmias, not chest pain alone. C: Correct - IV access is needed for potential medications. D: Incorrect - Urinary catheter is not indicated for chest pain. E: Correct - Nitroglycerin relieves ischemic chest pain.
The nurse has instructed a client who is scheduled to have a carotid ultrasound. Which of the following statements by the client would require follow up?
- A. I plan to eat a light meal before the ultrasound.
- B. I will remove any jewelry or metal objects from my neck before the procedure.
- C. I understand that the ultrasound will use sound waves to create images of my carotid arteries.
- D. I should fast for at least 8 hours before the ultrasound.
Correct Answer: D
Rationale: Carotid ultrasound does not require fasting, so this statement requires correction.
The nurse is planning care for a client admitted with infective endocarditis (IE). Which assessment finding would indicate that the client is experiencing a complication?
- A. petechial rashes
- B. flank pain
- C. headache
- D. fever
Correct Answer: B
Rationale: Flank pain may indicate renal embolism, a complication of infective endocarditis due to septic emboli.
The nurse is caring for a client and upon initial evaluation the nurse suspects femoral artery occlusion. The nurse should take which action?
- A. Elevate the affected leg
- B. Apply a cold compress
- C. Notify the primary healthcare provider (PHCP)
- D. Perform passive range of motion to the affected leg
Correct Answer: C
Rationale: Femoral artery occlusion is a medical emergency requiring immediate notification of the PHCP for vascular intervention.
The nurse is caring for a client with the following clinical data. Based on the laboratory tests, which medication would the nurse clarify with the primary healthcare provider (PHCP) prior to administration? See the exhibit for additional client information.
- A. bupropion 150 mg XL PO Daily
- B. clonidine 0.1 mg PO Daily
- C. albuterol 2.5 mg via nebulizer Daily
- D. captopril 12.5 mg PO Daily
Correct Answer: D
Rationale: Captopril, an ACE inhibitor, requires clarification if renal function is impaired (e.g., elevated creatinine), as it can worsen kidney injury.