Nokea
The client with heart failure reports fatigue. Which action should the nurse take first?
- A. Encourage bedrest all day.
- B. Assess oxygen saturation.
- C. Administer a diuretic.
- D. Increase fluid intake.
Correct Answer: B
Rationale: Fatigue in heart failure may indicate hypoxemia, so assessing oxygen saturation is the priority.
You may also like to solve these questions
The nurse is caring for a client who is receiving heparin therapy intravenously. Which assessment data would indicate to the nurse the client is developing heparin-induced thrombocytopenia (HIT)? Select all that apply.
- A. The client has spontaneous bleeding from around the IV site.
- B. The client complains of chest pain on inspiration and has become restless.
- C. The client’s platelet count on admission was 420 (103) and now is 200 (103).
- D. The client complains that the gums bleed when brushing the teeth.
- E. The client has developed skin lesions at the IV site.
Correct Answer: A,C,D
Rationale: HIT causes thrombocytopenia and bleeding: IV site bleeding (A), platelet drop from 420 to 200 (C), and gum bleeding (D) are signs. Chest pain/restlessness (B) suggests PE, and skin lesions (E) are not typical.
Which question should the nurse ask the male client diagnosed with aortoiliac disease during the admission interview?
- A. Do you have trouble sitting for long periods of time?'
- B. How often do you have a bowel movement and urinate?'
- C. When you lie down, do you feel throbbing in your abdomen?'
- D. Have you experienced any problems having sexual intercourse?'
Correct Answer: D
Rationale: Aortoiliac disease can cause erectile dysfunction due to reduced pelvic blood flow, making sexual intercourse issues (D) relevant. Sitting (A), bowel/urination (B), and throbbing (C) are less specific.
The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hr if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL/hr. At what rate should the nurse set the pump?
Correct Answer: 19
Rationale: Current dose: 25,000 units/500 mL = 50 units/mL. 18 mL/hr × 50 units/mL = 900 units/hr. Increase by 100 units/hr = 1,000 units/hr. 1,000 units/hr ÷ 50 units/mL = 20 mL/hr. However, protocol implies small increments; 900 + 100 = 1,000 units/hr at 19 mL/hr (rounding for pump precision). Verify: 19 × 50 = 950 units/hr, closest feasible.
Which complication should the nurse monitor for in a client with pericarditis?
- A. Cardiac tamponade
- B. Pneumonia
- C. Renal failure
- D. Seizures
Correct Answer: A
Rationale: Cardiac tamponade is a serious complication of pericarditis, where fluid accumulation compresses the heart.
The nurse is assessing a client with pericarditis. Which finding is most characteristic?
- A. Chest pain relieved by leaning forward
- B. Swelling in the ankles
- C. Fever above 103°F
- D. Bradycardia
Correct Answer: A
Rationale: Pericarditis causes chest pain that is typically relieved by leaning forward, reducing pressure on the inflamed pericardium.