Nokea
A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess?
- A. Pulmonary crackles
- B. Confusion, restlessness
- C. Pulmonary hypertension
- D. Dependent edema
- E. Cough that worsens at night
Correct Answer: A,B,E
Rationale: Left-sided heart failure leads to pulmonary congestion, causing pulmonary crackles, confusion, restlessness (due to hypoxia), and cough that worsens at night. Pulmonary hypertension and dependent edema are associated with right-sided heart failure.
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After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate correct understanding of the teaching related to nutritional intake?
- A. I should limit my fluid intake to 2 liters per day
- B. I need to avoid adding salt to my foods
- C. I should eat foods high in potassium, like bananas
- D. I must avoid foods high in vitamin K
- E. I will check food labels for sodium content
Correct Answer: A,B,C,E
Rationale: Clients with CHF should limit fluid intake (typically to 2 liters/day), avoid adding salt, eat potassium-rich foods (especially if on diuretics), and check sodium content. Avoiding vitamin K is specific to clients on warfarin, not a general CHF requirement.
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 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.
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 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.