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A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?
- A. Do you have trouble breathing or chest pain?
- B. Are you able to walk upstairs without fatigue?
- C. Do you awake with breathlessness during the night?
- D. Do you have new numbness in your legs?
Correct Answer: B
Rationale: Asking about the ability to walk upstairs without fatigue assesses functional capacity, which helps determine the extent of heart failure. The other questions address symptoms but do not directly evaluate the degree of limitation caused by heart failure.
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A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the priority nursing intervention?
- A. Oxygen saturation of 90%
- B. Dyspnea on exertion
- C. Mild systolic murmurs
- D. Upper extremity weakness
Correct Answer: B
Rationale: Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not directly indicate the progression of mitral valve stenosis.
A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include for this client's discharge teaching?
- A. Use a soft-bristled toothbrush and avoid flossing
- B. Avoid large crowds and people who are sick
- C. Monitor your heart rate before taking the medication
- D. Take the medication with a high-fat meal
Correct Answer: B
Rationale: Cyclosporine causes immune suppression, leaving the client more vulnerable to infection. Avoiding large crowds and sick people reduces infection risk. The medication does not increase bleeding risk, affect heart rate, or require a high-fat meal.
The presence of an S3 gallop is noted in a client. What should the nurse do?
- A. Assess for symptoms of left-sided heart failure
- B. Document this as a normal finding
- C. Call the health care provider immediately
- D. Transfer the client to the intensive care unit
Correct Answer: A
Rationale: The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.
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.
A nurse cares for a client with right-sided heart failure. The client asks, 'Why do I need to weigh myself every day?' How should the nurse respond?
- A. Daily weights will help us identify if you are gaining or losing fluid
- B. Daily weights will help us make sure that you're eating properly
- C. The hospital requires that all inpatients be weighed daily
- D. You need to lose weight to decrease the incidence of heart failure
Correct Answer: A
Rationale: Daily weights are critical for monitoring fluid retention or loss in clients with right-sided heart failure, as fluid accumulation is a key symptom of this condition. The other responses do not accurately address the purpose of daily weighing.