Heart Failure — Quiz

For a 54-year-old male client (Mr. Chen) in the emergency department with heart failure: "The client's cues are most consistent with ___; the nurse should first ___; and the outcome that shows the intervention worked is ___."

Select the options that correctly complete the nurse's clinical judgment.

• Athe complication most associated with this condition's pathophysiology
• Baddress airway, breathing, and circulation before anything else
• Cimprovement in the specific cue that drove the intervention (vitals, labs, symptoms)
• Danxiety — a benign reaction that needs no action
• Edocumentation completed at the end of shift

Mr. Chen (54, male) in the emergency department has heart failure. Shift assessment note: which findings require follow-up?

Select every finding below that is a cause for concern and requires follow-up.

• AA downward trend in oxygen saturation across two checks
• BA new report of worsening pain at the affected site
• CUrine output of 25 mL over the last hour
• DLung sounds unchanged from the client's documented baseline
• EA temperature that has remained in the normal range all shift

Unfolding case — Mr. Chen (54-year-old male), the emergency department, heart failure. Hour 0: stable on admission orders. Hour 4: new cue suggests early deterioration. Hour 6: cue persists despite the first intervention. Which nursing actions are appropriate across this unfolding case?

Select all that apply.

• APerform a focused reassessment at each time point and compare with baseline
• BTitrate or implement prescribed interventions per orders as cues evolve
• CEscalate with SBAR when the cue persists past the first intervention
• DWait for the next scheduled assessment before acting on the new cue
• EDocument cues, actions, and the client's response with times

Two nursing actions for a 54-year-old male client (Mr. Chen) in the emergency department with heart failure both appear correct. Which principle helps the nurse choose the best answer?

• AChoose the action that addresses the most urgent physiological threat (ABC/safety) first
• BChoose the action that takes the least time
• CChoose the action that requires the fewest supplies
• DChoose the action the client prefers

The nurse cares for a 29-year-old female client (Ms. Okafor) in a post-operative recovery bay admitted with heart failure. Which assessment finding requires the nurse's immediate action?

• AA new, rapidly worsening change in airway, breathing, or circulation
• BA chronic finding documented since admission
• CA mild discomfort rated 3/10 that is unchanged
• DA laboratory value that is within the reference range