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The home health nurse is caring for a client who experienced a myocardial infarction two weeks ago. Which of the following client statement requires immediate follow-up?
- A. I am having difficulty coping with the stress at work.
- B. I am unsure if I want to continue with cardiac rehabilitation.
- C. I have not been taking my prescribed clopidogrel because I cannot afford it.
- D. I started using nicotine patches to help me quit smoking.
Correct Answer: C
Rationale: Clopidogrel is critical for preventing stent thrombosis post-MI. Non-adherence requires urgent follow-up.
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While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action?
- A. Percuss over the area to assess for dullness
- B. Notify the primary healthcare provider (PHCP)
- C. Gently palpate the abdomen to assess for tenderness
- D. Ask the client about recent bowel movements
Correct Answer: B
Rationale: A swooshing sound may indicate an abdominal aortic aneurysm, a life-threatening condition requiring immediate PHCP notification.
The nurse is caring for a client with congestive heart failure (CHF). The nurse should anticipate a prescription for which medication?
- A. Enalapril
- B. Verapamil
- C. Lovastatin
- D. Gemfibrozil
Correct Answer: A
Rationale: Enalapril, an ACE inhibitor, reduces afterload and preload in CHF, improving cardiac function.
The following scenario applies to the next 6 items
The client is a 72-year-old male who presents to the emergency department with increasing
shortness of breath over the past two days that gets worse when he is lying flat in bed at night.
Item 1 of 6
History And Physical Nurses' Notes Flow Sheet
0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The
the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
Click to indicate whether each clinical finding is seen in left-sided heart failure, right-sided heart failure, or both.
- A. Crackles auscultated bilaterally
- B. Bilateral lower extremity edema
- C. Paroxysmal nocturnal dyspnea
- D. Fatigue
- E. Weight gain of 4 pounds
- F. Accessory muscle use
- G. Jugular vein distension
Correct Answer: A,B,C,D,E,F,G
Rationale: A: Left-sided - Crackles result from pulmonary edema in left heart failure. B: Right-sided - Edema is due to systemic venous congestion in right heart failure. C: Left-sided - Paroxysmal nocturnal dyspnea is caused by pulmonary congestion. D: Both - Fatigue occurs in both due to reduced cardiac output. E: Right-sided - Weight gain reflects fluid retention from right heart failure. F: Left-sided - Accessory muscle use indicates respiratory distress from pulmonary edema. G: Right-sided - Jugular vein distension is due to right heart failure.
Which of the following statements about sodium are true for a client newly diagnosed with hypertension? Select all that apply.
- A. Sodium cannot be completely eliminated from the diet.
- B. There is no sodium in fresh fruits and vegetables.
- C. Canned vegetables should be avoided.
- D. The body needs some sodium as it plays an important role in water balance.
- E. Reduce daily sodium intake to 2,000 mg
Correct Answer: A,C,D
Rationale: Sodium is naturally present in many foods, making complete elimination impossible. B: Incorrect - Fresh fruits and vegetables contain small amounts of sodium naturally. C: Correct - Canned vegetables are high in sodium and should be avoided or rinsed. D: Correct - Sodium is essential for fluid balance and nerve function. E: Incorrect - Guidelines recommend reducing sodium to 1,500 mg/day for hypertension, not 2,000 mg.
The nurse is visiting a client who was recently prescribed antihypertensive medications. Which statement, if made by the client, requires follow-up?
- A. My pulse decreases after taking my metoprolol.
- B. I started taking my furosemide right before I went to sleep.
- C. I am seasoning my foods with salt substitutes while taking my hydrochlorothiazide.
- D. I wear my clonidine patch for seven days.
Correct Answer: B
Rationale: Taking furosemide, a diuretic, at bedtime can cause nocturia, disrupting sleep and increasing fall risk. It should be taken earlier.