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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.
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A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching?
- A. Hold the next dose of Imdur
- B. Increase your intake of foods that are high in potassium
- C. Hold this medication if your pulse rate is below 90 beats per minute
- D. Do not take this medication within 1 hour of taking an antacid
Correct Answer: D
Rationale: Digoxin should not be taken within 1 hour of antacids, as antacids can decrease its absorption. Holding Imdur is irrelevant to digoxin therapy. Potassium intake needs monitoring, but hypokalemia (not high potassium) is a concern with digoxin. The pulse rate threshold for holding digoxin is typically below 60 beats per minute, not 90.
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.
A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis?
- A. A 36-year-old woman with systemic lupus erythematosus (SLE)
- B. A 52-year-old woman recovering from a myocardial infarction
- C. A 59-year-old woman recovering from cardiac surgery
- D. An 80-year-old man with a bacterial infection of the respiratory tract
- E. An 80-year-old woman with a stage III sacral ulcer
Correct Answer: A,B,D
Rationale: Acute pericarditis is associated with systemic connective tissue diseases like SLE, post-myocardial infarction (Dressler's syndrome), post-cardiac surgery inflammation, and bacterial infections. Stage III sacral ulcers do not increase the risk.
A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client?
- A. Teach the client about dietary restrictions
- B. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor
- C. Encourage the client to take a baby aspirin each day
- D. Provide a plan for worsening symptoms
- E. Consult a social worker for additional resources
Correct Answer: A,B,D
Rationale: The Heart Failure Core Measure Set includes discharge instructions on diet, medications (like ACE inhibitors), and a plan for worsening symptoms. Aspirin is typically for myocardial infarction, not heart failure, and social worker consultation is not part of the Core Measure Set.