Nokea
A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
- A. Assess the client's respiratory status
- B. Draw blood for sodium electrolytes
- C. Administer intravenous furosemide (Lasix)
- D. Ask the client about current medications
Correct Answer: A
Rationale: Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications in heart failure exacerbation. Monitoring electrolytes, administering diuretics, and asking about medications are important but do not take priority over assessing respiratory status.
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A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, 'Why will I need to take anticoagulants for the rest of my life?' How should the nurse respond?
- A. The prosthetic valve requires thinner blood to function properly
- B. Blood clots form more easily in artificial replacement valves
- C. The vein taken from your leg reduces circulation in the leg
- D. The surgery left a lot of small clots in your heart and lungs
Correct Answer: B
Rationale: Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.
A nurse assesses a client for signs of infective endocarditis. Which clinical manifestations should the nurse expect?
- A. Weight gain
- B. Night sweats
- C. Cardiac murmur
- D. Abdominal bloating
- E. Osler nodes
Correct Answer: B,C,E
Rationale: Clinical manifestations of infective endocarditis include night sweats, cardiac murmur, and Osler nodes. Weight gain and abdominal bloating are not typical; the latter is associated with heart transplant rejection.
A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?
- A. Premature ventricular contractions
- B. Atrial fibrillation
- C. Symptomatic bradycardia
- D. Sinus tachycardia
Correct Answer: B
Rationale: Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Premature ventricular contractions and bradycardia are not typically associated with valvular problems, and sinus tachycardia is linked to aortic regurgitation.
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?
- A. Would you like to speak with a priest or chaplain?
- B. I will arrange for a psychiatrist to speak with you
- C. Do you want to come off the transplant list?
- D. Would you like information about advance directives?
Correct Answer: D
Rationale: This client is verbalizing a real concern about negative outcomes of the surgery. Providing information about advance directives allows the client to express their wishes and feel some control over their future. The other responses do not directly address the client's concerns or empower them.
After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching?
- A. I'll be able to carry heavy loads after 6 months of rest
- B. I will have my teeth cleaned by my dentist in 2 weeks
- C. I must avoid eating foods high in vitamin K
- D. I will use an electric razor for shaving
Correct Answer: B
Rationale: Clients who have defective or repaired valves are at high risk for endocarditis. The client should avoid dental procedures for 6 months because of the risk for endocarditis. The other statements reflect correct understanding of post-surgery care.