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 client with symptoms of intermittent claudication receives treatment with a peripheral percutaneous transluminal angioplasty procedure with placement of an endovascular stent. Which statements, if made by the client, support the home-care nurse’s conclusion that the client is making lifestyle changes to decrease the likelihood of restenosis and arterial occlusion? Select all that apply.
- A. “I have been doing exercises twice daily.”
- B. “All nicotine products were thrown away.”
- C. “These support hose keep my legs warm.”
- D. “I see a podiatrist tomorrow for foot care.”
- E. “I'm following a low-saturated-fat diet”
- F. “I now take rosuvastatin calcium.”
Correct Answer: A;B;E;F
Rationale: The client’s statements indicating lifestyle changes are: A) Exercising to promote collateral circulation; B) Discontinuing nicotine to deter atherosclerosis; E) Following a low-saturated-fat diet to reduce atherosclerosis; F) Taking rosuvastatin to lower cholesterol. Support hose and podiatry care do not directly prevent restenosis.
The nurse is admitting the client with a thoracic aortic aneurysm. Which intervention should the nurse plan to include?
- A. Administering antihypertensive medications
- B. Palpating the abdomen to determine the aneurysm’s size
- C. Inserting a nasogastric tube set to moderate suction
- D. Teaching about a diet high in potassium and low in sodium
Correct Answer: A
Rationale: The nurse should include administering antihypertensive medications to the client with a thoracic aortic aneurysm; controlling HR and BP is important to decrease the risk of aneurysm rupture. Palpation is contraindicated, and NG tubes or specific diets are not indicated.
The nurse is admitting the client experiencing dyspnea from HF and COPD with high CO2 levels. Which interventions should the nurse plan? Select all that apply.
- A. Apply oxygen 6 liters per nasal cannula.
- B. Elevate the head of the bed 30 to 40 degrees.
- C. Weigh daily in the am. after the client voids.
- D. Teach client pursed-lip breathing techniques.
- E. Turn and reposition the client every 1 to 2 hours.
Correct Answer: B;C;D
Rationale: The nurse should plan: B) Elevating the head of the bed to promote lung expansion; C) Daily weights to assess fluid retention; D) Pursed-lip breathing to conserve energy and slow breathing. High oxygen flow (A) may depress hypoxic drive in COPD, and repositioning (E) is less specific to dyspnea management.
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.
While preparing the client for a computed tomography angiography (CTA), the client asks the nurse what the test Will entail. Which should be the nurse’s correct response?
- A. “A CTA uses magnetic fields to visualize the major vessels Within your body.”
- B. “A CTA is an invasive procedure that requires a small incision into an artery.”
- C. “A CTA is a quick procedure that requires anesthesia for about 20 minutes.”
- D. “A CTA is a scan that includes a contrast dye injection to visualize your arteries.”
Correct Answer: D
Rationale: The correct response should explain CTA. CTA is a noninvasive spiral CT scan using contrast dye to yield a 3-dimensional image of the arteries. It does not use magnetic fields (A), require incisions (B), or anesthesia (C).