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The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client?
- A. Do not lift or carry more than 23 kg.
- B. Have someone drive the car for the rest of your life.
- C. Carry the cell phone on the opposite side of the ICD.
- D. Avoid using the microwave oven in the home.
Correct Answer: C
Rationale: Carrying the cell phone on the opposite side (C) minimizes electromagnetic interference with the ICD. Lifting limits (A) are typically 10–15 lbs initially, driving (B) is restricted temporarily, and microwaves (D) are safe.
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The nurse has written an outcome goal 'demonstrates tolerance for increased activity' for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?
- A. Measure intake and output.
- B. Provide two (2)g sodium diet.
- C. Weigh the client daily.
- D. Plan for frequent rest periods.
Correct Answer: D
Rationale: Frequent rest periods (D) prevent overexertion, supporting activity tolerance in CHF. Intake/output (A), sodium diet (B), and daily weights (C) are important but less directly related to activity.
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.
The nurse is working with a group of new graduates on a medical-surgical unit. Which should the nurse explain about completing first morning rounds on clients?
- A. Perform a 'down and dirty' assessment on each client soon after receiving report.
- B. Determine which client should have a bath and inform the unlicensed assistive personnel.
- C. Give all the clients a wet wash to wash the face and a toothbrush and toothpaste.
- D. Pick up any paper on the floor and get the room ready for morning physician rounds.
Correct Answer: A
Rationale: A quick 'down and dirty' assessment (A) prioritizes client stability post-report. Bathing (B), hygiene (C), and room prep (D) are secondary to safety.
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.