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The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor?
- A. The client admitted for diagnostic tests to rule out valvular heart disease.
- B. The client three (3) days post-myocardial infarction being discharged tomorrow.
- C. The client exhibiting supraventricular tachycardia (SVT) on telemetry.
- D. The client diagnosed with atrial fibrillation who has an INR of five (5).
Correct Answer: A
Rationale: Diagnostic testing for valvular disease (A) is stable, suitable for a new graduate. Post-MI (B), SVT (C), and high INR (D) require experienced care.
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The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
- A. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
- B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
- C. Instruct the client to remove the saltshaker from the dinner table.
- D. Encourage the client to monitor urine output for change in color to become dark.
- E. Discuss the importance of taking the loop diuretic furosemide at bedtime.
Correct Answer: A,B,C
Rationale: Weight gain monitoring (A) detects fluid retention, pulse counting (B) ensures digoxin safety, and removing salt (C) reduces sodium intake. Dark urine (D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.
The nurse is administering morning medications. Which medication should be administered first?
- A. The cardiac glycoside medication, digoxin, to a client diagnosed with heart failure and who has 2+ edema of the feet.
- B. The sliding scale insulin to a client with a fasting blood glucose of 345 mg/dL who is demanding breakfast.
- C. The loop diuretic, furosemide, to a client with a 24-hour intake of 986 mL and an output of 1,400 mL.
- D. The ARB medication to a client whose blood pressure was reported by the unlicensed assistive personnel as 142/76.
Correct Answer: B
Rationale: Fasting glucose of 345 mg/dL (B) requires immediate insulin to prevent complications, especially before eating. Digoxin (A), furosemide (C), and ARB (D) are less urgent.
What is the priority problem in the client diagnosed with congestive heart failure?
- A. Fluid volume overload.
- B. Decreased cardiac output.
- C. Activity intolerance.
- D. Knowledge deficit.
Correct Answer: B
Rationale: Decreased cardiac output (B) is the primary problem in CHF, causing symptoms like fluid overload (A). Activity intolerance (C) and knowledge deficit (D) are secondary.
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
- A. Assist the client to go down to the smoking area for a cigarette.
- B. Transport the client to the intensive care unit (ICU) via a stretcher.
- C. Provide the client going home discharge-teaching instructions.
- D. Help position the client who is having a portable x-ray done.
Correct Answer: D
Rationale: Positioning for an x-ray (D) is within the UAP’s scope and safe. Smoking (A) is inappropriate, ICU transport (B) requires nursing judgment, and discharge teaching (C) is a nursing responsibility.
The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure?
- A. Perform passive range-of-motion exercises.
- B. Assess the client's neurovascular status.
- C. Keep the client in high Fowler's position.
- D. Assess the gag reflex prior to feeding the client.
Correct Answer: B
Rationale: Post-catheterization, assessing neurovascular status (B) ensures no bleeding or vascular complications. ROM (A) is inappropriate, high Fowler’s (C) is not required, and gag reflex (D) is irrelevant.