Difficulty: Medium
Average Score: 75%
Simulated
Passage / Scenario
Vital SignsDiagnostic Results
Nurses Notes
Temperature 37.2┬░ C (98.9┬░ F)
Heart rate 138/min
Respiratory rate 28/min
Blood pressure 96/75 mm Hg
Oxygen saturation 93%
A nurse is admitting a client who has a history of heart failure. Check the 5 findings that require immediate follow-up.
Correct answer
A,B,C,E,F
Rationale
Vital signs (A), respiratory assessment (B), renal function (C), BNP (E), and ECG results (F) require immediate follow-up due to tachycardia, tachypnea, possible pulmonary edema, kidney impairment, and atrial fibrillation. Cardiac enzymes and neurologic status are less urgent.