Nokea
The client with class II HF according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes which component?
- A. Diuretics
- B. A low-sodium diet
- C. Home oxygen therapy
- D. Angiotensin-converting enzyme (ACE) inhibitors
Correct Answer: C
Rationale: In class II HF, normal physical activity results in fatigue, dyspnea, palpitations, or anginal pain, but symptoms are absent at rest. Home oxygen therapy is unnecessary unless there are other comorbid conditions. Diuretics, low-sodium diet, and ACE inhibitors are standard treatments.
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The nurse is discussing healthy lifestyle practices with the client who has chronic venous insufficiency. Which practices should be emphasized with this client? Select all that apply.
- A. Avoid eating an excess of dark green vegetables.
- B. Take rests and elevate the legs while sitting.
- C. Wear graduated compression stockings, removing them at night.
- D. Increase standing time and shift weight when upright.
- E. Sleep with legs elevated above the level of the heart.
Correct Answer: B;C;E
Rationale: The nurse should emphasize: B) Elevating legs when sitting to promote venous return; C) Wearing compression stockings to reduce edema; E) Sleeping with legs elevated to enhance venous return. Avoiding dark green vegetables is relevant only with anticoagulants, and prolonged standing should be avoided.
The nurse is assessing the client who underwent repair of an aortic aneurysm with graft placement 30 minutes ago. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. What should be the nurse’s priority?
- A. Recheck the pulse in 5 minutes.
- B. Reposition the affected leg.
- C. Notify the surgeon of the finding.
- D. Document that the pulse is absent.
Correct Answer: C
Rationale: The nurse should notify the surgeon immediately to reassess the client. The loss of the pulse could signify graft occlusion or embolization. Rechecking, repositioning, or documenting delays critical intervention.
The nurse is caring for the client immediately following insertion of a permanent pacemaker via the right subclavian vein approach. Which intervention should the nurse include in the client’s plan of care to best prevent pacemaker lead dislodgement?
- A. Inspect the incision for approximation and bleeding
- B. Prevent the right arm from going above shoulder level
- C. Assist the client with using a walker when out of bed
- D. Request a STAT chest x-ray upon return from the procedure
Correct Answer: B
Rationale: Limiting arm and shoulder activity initially and up to 24 hours after the pacing leads are implanted helps prevent lead dislodgement. Often an arm sling is used as a reminder to the client to limit arm activity. Inspecting the incision, using a walker, and chest x-ray do not directly prevent lead dislodgement.
The client returns to a hospital unit after undergoing placement of a vena cava filter. Which intervention should the nurse implement?
- A. Restart heparin therapy as soon as possible.
- B. Reinforce the abdominal incision dressing.
- C. Inspect the groin insertion site for bleeding.
- D. Increase fluids to promote excretion of the dye.
Correct Answer: C
Rationale: The procedure for placement of a vena cava filter is done percutaneously, usually through the subclavian or femoral vein approach. The nurse should check the groin insertion site for bleeding. Heparin is unnecessary, there’s no abdominal incision, and dye is not used.
The nurse observes that the client, 3 days post MI, seems unusually fatigued. Upon assessment, the client is dyspneic with activity, has sinus tachycardia, and has generalized edema. Which action by the nurse is most appropriate?
- A. Administer high-flow oxygen.
- B. Encourage the client to rest more.
- C. Continue to monitor the client’s heart rhythm.
- D. Compare the client’s admission and current weight.
Correct Answer: D
Rationale: A complication of MI is HF. Signs of HF include fatigue, dyspnea, tachycardia, edema, and weight gain. Comparing admission and current weight assesses fluid retention, a key indicator of HF severity. High-flow oxygen is unnecessary without hypoxia, rest alone won’t address HF, and monitoring rhythm delays intervention.