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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Which assessment finding best supports the assumption that the client is a good treatment.
- A. Pericardial friction rub
- B. Muffled heart sounds
- C. S3 gallop
- D. Systolic murmur
Correct Answer: A
Rationale: Pericardial friction rub is characteristic of pericarditis due to inflamed pericardial layers.
Which symptom would the nurse expect to observe if the client is having an allergic reaction to streptokinase (Streptase)?
- A. Urticaria
- B. Anuria
- C. Hemoptysis
- D. Dyspepsia
Correct Answer: A
Rationale: Urticaria (hives) is a common sign of an allergic reaction to streptokinase, a thrombolytic agent.
The nurse assessing the client with pericardial effusion at 1600 notes the apical pulse is 72 and the BP is 138/94. At 1800, the client has neck vein distention, the apical pulse is 70, and the BP is 106/94. Which action would the nurse implement first?
- A. Stay with the client and use a calm voice.
- B. Notify the health-care provider immediately.
- C. Place the client left lateral recumbent.
- D. Administer morphine intravenous push slowly.
Correct Answer: B
Rationale: JVD and hypotension (BP drop to 106/94) suggest cardiac tamponade; notifying the HCP (B) is urgent. Staying calm (A), lateral position (C), and morphine (D) are secondary.
Before administering the digoxin (Lanoxin) to the client, what nursing assessment is essential?
- A. The client's heart rate
- B. The client's blood pressure
- C. The client's heart sounds
- D. The client's breath sounds
Correct Answer: A
Rationale: Check heart rate; withhold digoxin if <60 bpm to prevent toxicity.
A female client is admitted to the hospital with obesity and deep vein thrombophlebitis (DVT) of the right leg. She weighs 275 pounds. Which of the following factors is least related to her diagnosis?
- A. She has been taking oral estrogens for the last three years.
- B. She smokes two packs of cigarettes daily.
- C. Her right femur was fractured recently.
- D. She is 30 years old.
Correct Answer: D
Rationale: Age (30 years) is the least related to DVT risk compared to estrogen use, smoking, and recent fracture, which are known risk factors for thrombosis.