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The emergency department nurse is caring for a client with congestive heart failure who reports dyspnea and a persistent cough. The nurse obtains the client's vital signs and suspects that the client is experiencing which condition? See the image below.
- A. Pulmonary embolism
- B. Hypovolemic shock
- C. Disseminated intravascular coagulation (DIC)
- D. Pulmonary edema
Correct Answer: D
Rationale: Dyspnea and persistent cough in CHF suggest pulmonary edema due to fluid backup in the lungs.
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Which of the following statements by the client with atrial fibrillation would require a follow-up? Select all that apply.
- A. I have an increased risk for a stroke.
- B. I should weigh myself daily at the same time.
- C. I may be prescribed medications such as amiodarone.
- D. I should wear a mask when I am in public.
- E. I should seek medical care if I develop shortness of breath.
Correct Answer: B,D
Rationale: Atrial fibrillation increases stroke risk due to clot formation; no follow-up needed. B: Incorrect - Daily weighing is more relevant for heart failure, not atrial fibrillation; requires clarification. C: Correct - Amiodarone is a common medication for atrial fibrillation; no follow-up needed. D: Incorrect - Wearing a mask in public is not related to atrial fibrillation management; requires clarification. E: Correct - Shortness of breath could indicate complications; no follow-up needed.
The nurse in the emergency department (ED) is assessing a client who may have an acute myocardial infarction. Which of the following findings would support this diagnosis?
- A. U-waves
- B. T-wave inversion
- C. ST-segment elevation
- D. Prolonged PR-interval
Correct Answer: C
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
The nurse performs a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened non-tender maculae on the hands and feet. The nurse understands that these are
- A. Heberden's nodes
- B. Janeway lesions
- C. Tophi
- D. Bouchard's nodes
Correct Answer: B
Rationale: Janeway lesions are non-tender, erythematous maculae on the palms and soles, characteristic of infective endocarditis.
The nurse is caring for a client with myocardial infarction (MI), who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following?
- A. Observe for neurological changes
- B. Monitor for any signs of renal failure
- C. Observe for signs of bleeding
- D. Check the client's food diary
Correct Answer: C
Rationale: tPA is a thrombolytic that increases bleeding risk. Monitoring for signs of bleeding (e.g., hematoma, gastrointestinal bleeding) is critical.
The following scenario applies to the next 1 items
The nurse in the outpatient clinic is caring for a 37-year-old male client
Item 1 of 1
Nurses' Note Physician Orders Current Medications
1100: The client reports intermittent dizziness that started following the dosage increase of his prescribed spironolactone one week ago. The client states that it is worse for a few hours after he takes the medication but then resolves. On assessment, the client is alert and oriented. The client's breathing is unlabored and has clear lung fields bilaterally. Skin warm to the touch and pink in tone; pulses 2+ and regular. Capillary refill is 3 seconds. He denies any pain.
Vital signs: T 98.6° F (37° C), P 76, RR 16, BP 130/86, pulse oximetry reading 98% on room air. Medical history of hypertension and hyperlipidemia.
The nurse prepares to obtain the client's orthostatic blood pressure (BP) by first positioning the client …………. then positioning the client …………. the client …………. When obtaining the blood pressure, the nurse should ……………….. The nurse should be concerned for orthostatic hypotension if the systolic blood pressure decreases by ………….. or the diastolic blood pressure decreases by……………….
- A. Standing
- B. Supine
- C. Sitting
- D. Obtain the blood pressure with the client's arm in the dependent position.
- E. Keep the blood pressure cuff in the same position.
- F. Obtain BP readings 10 minutes after the client changes position.
- G. 20 mm Hg
Correct Answer: B,C,A,E,G
Rationale: Orthostatic BP is measured supine (B), then sitting (C), then standing (A). The cuff should stay in the same position (E). A drop of 20 mm Hg systolic (G) or 10 mm Hg diastolic