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The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse implement when providing care for the client?
- A. Take daily weights and monitor trends.
- B. Encourage fluid intake to improve hydration.
- C. Elevate the legs above the level of the heart.
- D. Position the client supine with the head of the bed at 30 degrees.
Correct Answer: A
Rationale: Elevated BNP levels are indicative of heart failure, which often causes fluid retention and weight gain. Taking daily weights and monitoring trends allows the nurse to assess for changes in fluid status. This intervention helps in evaluating the effectiveness of the treatment plan and identifying worsening heart failure symptoms early.
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The healthcare provider is preparing to assist in the care of a client who has just returned from coronary artery bypass graft (CABG) surgery. Which is the priority action?
- A. Monitor the client's urine output.
- B. Check the client's surgical dressing.
- C. Measure the client's blood pressure.
- D. Assess the client's level of consciousness.
Correct Answer: D
Rationale: Assessing the client's level of consciousness is the priority action post-CABG surgery to monitor for signs of cerebral hypoxia or other complications that require immediate intervention. Changes in the client's level of consciousness can indicate neurological deterioration, which is critical to address promptly in this postoperative period.
The healthcare provider notes this rhythm on the client's cardiac monitor. The healthcare provider next reports that the client is experiencing which heart rhythm?
- A. Normal sinus
- B. Atrial fibrillation
- C. Sinus bradycardia
- D. Ventricular fibrillation
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with peripheral arterial disease complains of leg pain while walking. The nurse should reinforce which teaching point with the client?
- A. Wear compression stockings daily.
- B. Increase daily walking distance gradually.
- C. Elevate legs above heart level when resting.
- D. Use a heating pad to soothe leg muscles.
Correct Answer: B
Rationale: For clients with peripheral arterial disease experiencing leg pain while walking, gradually increasing daily walking distance is beneficial. This approach helps improve circulation, build tolerance, and reduce symptoms over time. Compression stockings can also be recommended for some clients to assist with circulation, but the priority teaching point in this scenario is to promote gradual increases in walking distance to enhance vascular health and symptom management.
A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems?
- A. Anterior chest pain
- B. Pericardial friction rub
- C. Weakness and irritability
- D. Chest pain that worsens with inspiration
Correct Answer: B
Rationale: Pericardial friction rub is a distinctive sign of pericarditis, characterized by a scraping or grating sound heard on auscultation, which helps differentiate pericarditis from other cardiopulmonary conditions. Anterior chest pain may be present in various cardiopulmonary issues. Weakness and irritability are nonspecific symptoms, and chest pain worsening with inspiration is more indicative of pleuritic conditions.
The client with Raynaud's phenomenon is being taught by the nurse about preventing episodes. Which instruction should the nurse reinforce?
- A. Wear gloves in cold weather.
- B. Avoid caffeine and chocolate.
- C. Increase intake of vitamin C.
- D. Use a heating pad for warmth.
Correct Answer: A
Rationale: Wearing gloves in cold weather is essential for preventing vasoconstriction and subsequent episodes of Raynaud's phenomenon. Cold temperatures can trigger vasospasms in individuals with Raynaud's, and wearing gloves helps maintain warmth and prevent the constriction of blood vessels in the extremities, reducing the likelihood of an episode.