Nokea
Because the client is exhibiting signs and symptoms of congestive heart failure (CHF), which position suggested by the nurse is most beneficial for the client at this time?
- A. Supine with knees slightly bent
- B. Side-lying on the right side
- C. Side-lying on the left side
- D. Semi-Fowler's position
Correct Answer: D
Rationale: Semi-Fowler's position (30-45 degrees) reduces preload and eases breathing in CHF.
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Which risk factor is least likely to have predisposed the client to having a myocardial infarction (MI)?
- A. Smoking cigarettes
- B. Eating fatty foods
- C. Working under emotional stress
- D. Drinking an occasional cocktail
Correct Answer: D
Rationale: Occasional alcohol consumption is the least significant MI risk factor compared to smoking, high-fat diets, and chronic stress.
A client who has been treated for angina is discharged in stable condition. At a clinic visit, he tells the nurse he has anginal pain when he has sexual intercourse with his wife. What is the best response for the nurse to make?
- A. Do you have ambivalent feelings toward your wife?'
- B. Many persons with angina have less pain when their partner assumes the top position.'
- C. Be sure that you attempt intercourse only when you are well rested and relaxed.'
- D. You might try having a cocktail before sexual activity to help you relax.'
Correct Answer: C
Rationale: Engaging in sexual activity when well-rested and relaxed reduces cardiac demand, minimizing angina risk. Questioning feelings, suggesting positions, or recommending alcohol are less appropriate or potentially harmful.
The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement?
- A. Restrict the client's fluids as ordered.
- B. Keep the client in the supine position.
- C. Maintain oxygen saturation at 90%.
- D. Monitor the total parenteral nutrition.
Correct Answer: A
Rationale: Fluid restriction (A) prevents overload post-mitral valve surgery. Supine position (B) increases preload, SpO2 90% (C) is too low, and TPN (D) is not routine.
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.
The nurse knows that the client understands the physician's explanation of the PTCA procedure when the client makes which statement?
- A. A balloon-tipped catheter will be inserted into my coronary artery.
- B. A Teflon graft will be used to replace an area of my artery.
- C. A section of my leg vein will be grafted around a narrowed coronary artery.
- D. A battery-operated pacemaker will be implanted to maintain my heart rate.
Correct Answer: A
Rationale: PTCA involves inflating a balloon-tipped catheter to open a narrowed coronary artery, improving blood flow.