Nokea
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.
You may also like to solve these questions
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?
- A. Administer amiodarone, an antidysrhythmic, IVP.
- B. Prepare to defibrillate the client.
- C. Assess the client's apical pulse and blood pressure.
- D. Start basic cardiopulmonary resuscitation.
Correct Answer: C
Rationale: Ventricular tachycardia requires assessing pulse/BP (C) to determine if it’s pulseless (defibrillation, B) or stable (amiodarone, A). CPR (D) is for pulseless states.
Which statement by the nurse is the best explanation for why the client needs to take the prescribed medication?
- A. It may destroy the virus causing your disease.
- B. It may reduce the scar tissue on the valve.
- C. It may stop blood clots from forming.
- D. It may prevent future bacterial infections.
Correct Answer: D
Rationale: Nafcillin is an antibiotic used to prevent bacterial endocarditis in valvular disease.
Which interventions should the nurse discuss with the client diagnosed with coronary artery disease? Select all that apply.
- A. Instruct the client to stop smoking.
- B. Encourage the client to exercise three (3) days a week.
- C. Teach about coronary vasodilators.
- D. Prepare the client for a carotid endarterectomy.
- E. Eat foods high in monosaturated fats.
Correct Answer: A,B,C
Rationale: Stopping smoking (A), exercising (B), and vasodilators (C) reduce CAD progression. Carotid endarterectomy (D) is for stroke risk, and monounsaturated fats (E) are beneficial but not high amounts.
After the femoral artery has been cannulated and the client is returned to the room, what should the nurse plan to do first?
- A. Palpate the client's distal peripheral pulses10 pulses.
- B. Auscultate the client's heart and breath sounds.
- C. Percuss all four quadrants of the client's abdomen.
- D. Inspect the skin integrity in the client's groin.
Correct Answer: A
Rationale: Palpating distal pulses first ensures adequate circulation post-catheterization, detecting complications like arterial occlusion.
While the client takes propranolol (Inderal), what changes would the nurse expect to see in the client's pulse rate?
- A. Faster than usual
- B. No longer detectable
- C. Temporarily irregular
- D. Slower than in the past
Correct Answer: D
Rationale: Propranolol slows the heart rate by blocking beta-adrenergic receptors, reducing sympathetic stimulation.