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An emergency department nurse is caring for a client who presented with fatigue, muscular weakness, and dyspnea. Upon assessment, the client was noted to be coughing frequently and sitting in a tripod position. A subsequent diagnosis of left ventricular failure was made. The nurse understands that manifestations of left-sided heart failure present as respiratory issues because:
- A. There is venous congestion in the liver.
- B. There is hypoperfusion of tissue cells.
- C. There is pulmonary congestion.
- D. Despite normal cardiac output, the heart cannot meet the accelerated demands of the body.
Correct Answer: C
Rationale: Left-sided heart failure causes pulmonary congestion, leading to respiratory symptoms like dyspnea and cough.
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The nurse is discharging a client with heart failure who is prescribed digoxin and furosemide. Which of the following laboratory tests must the client have monitored due to this combination of prescribed medications?
- A. Fecal occult blood
- B. Serum electrolytes
- C. Urinalysis
- D. Glycosylated hemoglobin
Correct Answer: B
Rationale: Furosemide can cause hypokalemia, increasing digoxin toxicity risk, so serum electrolytes (especially potassium) must be monitored.
Which of the following statements should the nurse include when teaching a community health course on adult cardiopulmonary resuscitation (CPR)? Select all that apply.
- A. The compression rate is 100 to 120 per minute.
- B. The compression depth should be 1.5 inches.
- C. Allow full chest recoil between compressions.
- D. Rotate compressor at least every 2 minutes.
- E. Stop to check your pulse every 30 seconds.
Correct Answer: A,C,D
Rationale: Compression rate of 100-120/min ensures adequate circulation. B: Incorrect - Depth should be 2-2.4 inches in adults. C: Correct - Full chest recoil maximizes venous return. D: Correct - Rotating compressors prevents fatigue. E: Incorrect - Pulse checks are done after rhythm checks, not every 30 seconds.
The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis?
- A. Basic metabolic panel (BMP)
- B. B-type natriuretic peptide (BNP)
- C. Lipid profile
- D. Troponin
Correct Answer: B
Rationale: BNP is a specific biomarker elevated in heart failure, reflecting ventricular stress and fluid overload.
The nurse is teaching a client who is scheduled for an exercise electrocardiography (ECG) test. Which of the following statements by the client would require follow-up?
- A. I should wear loose, comfortable clothing with non-slip athletic footwear.
- B. I may have a small cup of coffee before the exam.
- C. I will have my blood pressure, heart rate, and rhythm obtained before, during, and after the stress test.
- D. I should not do any strenuous activity before the test.
Correct Answer: B
Rationale: Caffeine can affect heart rate and ECG results, so coffee should be avoided before an exercise ECG test.
The nurse is visiting a client who was recently prescribed antihypertensive medications. Which statement, if made by the client, requires follow-up?
- A. My pulse decreases after taking my metoprolol.
- B. I started taking my furosemide right before I went to sleep.
- C. I am seasoning my foods with salt substitutes while taking my hydrochlorothiazide.
- D. I wear my clonidine patch for seven days.
Correct Answer: B
Rationale: Taking furosemide, a diuretic, at bedtime can cause nocturia, disrupting sleep and increasing fall risk. It should be taken earlier.