Nokea
An adult client is admitted with a diagnosis of left-sided congestive heart failure. Which assessment finding would most likely be present?
- A. Distended neck veins
- B. Dyspnea
- C. Hepatomegaly
- D. Pitting edema
Correct Answer: B
Rationale: Dyspnea is a hallmark symptom of left-sided congestive heart failure due to pulmonary congestion. Distended neck veins, hepatomegaly, and pitting edema are more associated with right-sided heart failure.
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When providing dietary instructions for this client, which healthful alternative should the nurse recommend?
- A. Wheat toast for white bread
- B. Margarine for butter
- C. Cereal for eggs
- D. Ham for sausage
Correct Answer: C
Rationale: Cereal is a low-cholesterol, heart-healthy alternative to eggs, which are high in cholesterol. Wheat toast and margarine still contain some fats, and ham is high in sodium and fat.
Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy?
- A. Keep the client in the supine position with the legs elevated.
- B. Discuss a heart transplant, which is the definitive treatment.
- C. Prepare the client for coronary artery bypass graft.
- D. Teach the client to take a calcium channel blocker in the morning.
Correct Answer: B
Rationale: Dilated cardiomyopathy may require heart transplant (B) as definitive treatment in severe cases. Supine position (A) increases preload, CABG (C) is for CAD, and calcium channel blockers (D) are not first-line.
Which prothrombin time value would be considered normal for a client who is receiving warfarin (Coumadin)?
- A. 12 seconds
- B. 20 seconds
- C. 60 seconds
- D. 98 seconds
Correct Answer: B
Rationale: For a client receiving warfarin, the prothrombin time should be 1.5 to 2 times the normal value (11 to 12.5 seconds). Twenty seconds falls within this therapeutic range. Twelve seconds is normal for someone not on warfarin. Sixty seconds is normal for a partial thromboplastin time (PTT) test, and 98 seconds would be therapeutic for heparin, not warfarin.
The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client?
- A. Apical pulse rate of 110 and 4+ pitting edema of feet.
- B. Thick white sputum and crackles that clear with cough.
- C. The client sleeping with no pillow and eupnea.
- D. Radial pulse rate of 90 and CRT less than three (3) seconds.
Correct Answer: A
Rationale: CHF exacerbation causes fluid overload, leading to tachycardia (apical pulse 110) and severe edema (4+ pitting, A). Thick sputum/crackles (B) suggest pneumonia, sleeping flat with eupnea (C) is unlikely, and normal CRT (D) doesn’t reflect CHF severity.
Which nursing action would best reduce the client's energy, the client?
- A. Administering oxygen when the client is dyspneic
- B. Staggering self-care activities over several hours
- C. Providing analgesic medications when necessary
- D. Restricting visitors to brief periods of time
Correct Answer: B
Rationale: Staggering activities conserves energy, reducing cardiac workload in recovery.