Nokea
The home health nurse is assigned a client diagnosed with heart failure. Which should the nurse implement? Select all that apply.
- A. Request a dietary consult for a sodium-restricted diet.
- B. Instruct the client to elevate the feet during the day.
- C. Teach the client to weigh every morning wearing the same type of clothing.
- D. Assess for edema in dependent areas of the body.
- E. Encourage the client to drink at least 3,000 mL of fluid per day.
- F. Have the client repeat back instructions to the nurse.
Correct Answer: A,B,C,D,F
Rationale: Sodium restriction (A), elevating feet (B), daily weights (C), edema assessment (D), and teach-back (F) manage CHF. 3,000 mL fluid (E) risks overload.
You may also like to solve these questions
The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in one (1) minute.
- B. The client diagnosed with coronary artery disease who wants to ambulate.
- C. The client diagnosed with mitral valve prolapse with an audible S3.
- D. The client diagnosed with pericarditis who is in normal sinus rhythm.
Correct Answer: C
Rationale: An S3 in mitral valve prolapse (C) suggests heart failure, requiring immediate assessment. Unifocal PVCs (A) are less urgent, ambulation (B) is routine, and normal rhythm in pericarditis (D) is stable.
The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement?
- A. Perform isometric exercises daily.
- B. Walk for 15 minutes three (3) times a week.
- C. Do not walk outside if it is less than 40°F.
- D. Wear open-toed shoes when ambulating.
Correct Answer: B
Rationale: Walking 15 minutes 3 times a week (B) is a safe, aerobic exercise for CAD. Isometric exercises (A) increase BP, cold weather (C) is a precaution, and open-toed shoes (D) are irrelevant.
The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?
- A. Social worker.
- B. Physical therapy.
- C. Cardiac rehabilitation.
- D. Occupational therapy.
Correct Answer: C
Rationale: Cardiac rehabilitation (C) promotes recovery through exercise and education post-MI. Social work (A), physical therapy (B), and occupational therapy (D) are less specific.
Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation?
- A. Defibrillate the client at 50, 100, and 200 joules.
- B. Do not remove the oxygen source during defibrillation.
- C. Place petroleum jelly on the defibrillator pads.
- D. Shout 'all clear' prior to defibrillating the client.
Correct Answer: D
Rationale: Shouting 'all clear' (D) ensures safety before defibrillation. Energy levels (A) are 200–360 joules, oxygen (B) is removed to prevent fire, and petroleum jelly (C) is not used.
The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?
- A. Muffled heart sounds.
- B. Nondistended jugular veins.
- C. Bounding peripheral pulses.
- D. Pericardial friction rub.
Correct Answer: A
Rationale: Muffled heart sounds (A) suggest cardiac tamponade, a life-threatening complication requiring immediate attention. Non-distended JVD (B) is normal, bounding pulses (C) are unrelated, and friction rub (D) is expected.