Nokea
The healthcare provider is monitoring a client with left-sided heart failure. Which assessment finding indicates that the client's condition is worsening?
- A. Clear lung sounds
- B. Increased peripheral pulses
- C. Bibasilar crackles
- D. Improved activity tolerance
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?
- A. Shave the front of the client's chest
- B. Give the client a device holder to wear around the waist
- C. Teach the client to rest as much as possible during the next 24 hours
- D. Tell the client to cover the monitor in plastic wrap before taking a bath
Correct Answer: B
Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings.
A healthcare provider is assisting in the care of a client who is having central venous pressure (CVP) measurements taken. The healthcare provider should assist by placing the bed in which position for the reading?
- A. Flat
- B. Semi-Fowler's
- C. Trendelenburg
- D. Reverse Trendelenburg
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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.
The client at risk for thrombophlebitis receives reinforcement from the LPN/LVN regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?
- A. I should avoid sitting for prolonged periods.
- B. I will take frequent walks and avoid prolonged bed rest.
- C. I should drink plenty of fluids to stay hydrated.
- D. I will use compression stockings as advised by my doctor.
Correct Answer: B
Rationale: The correct answer is B. Taking frequent walks and avoiding prolonged bed rest are essential measures to promote circulation and reduce the risk of thrombophlebitis. Physical activity helps prevent blood from pooling and clotting in the veins, thus decreasing the likelihood of thrombophlebitis development.
While preparing a client for a cardiac catheterization, the client expresses a preference to speak with their doctor rather than the nurse. Which response by the nurse should be therapeutic?
- A. Your doctor expects me to prepare you for this procedure.
- B. That's fine, if that's what you want. I'll call your health care provider.
- C. So you're saying that you want to talk to your health care provider?
- D. I'm concerned with the way you've dismissed me. I know what I am doing.
Correct Answer: C
Rationale: The therapeutic response by the nurse in this situation involves reflecting the client's feelings back to them, which demonstrates active listening and empathy. By restating the client's preference to talk to their doctor, the nurse acknowledges and validates the client's feelings, thereby fostering a positive therapeutic relationship and promoting open communication.