Nokea
The nurse assessed a client's cardiac rhythm strip. The nurse should plan to document this rhythm as which of the following? See the image below.
- A. Ventricular fibrillation
- B. Complete (3rd degree) heart block
- C. Sinus tachycardia
- D. Sinus bradycardia
Correct Answer: A
Rationale: Ventricular fibrillation is a chaotic, life-threatening rhythm requiring immediate defibrillation.
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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.
The client reporting …………… and …………….would indicate improvement in their condition.
- A. Ambulation tolerance
- B. Edema after activity
- C. Weight loss
- D. Sleeping in bed
- E. High sodium intake
Correct Answer: A,D
Rationale: A: Improved ambulation tolerance indicates better functional capacity. D: Sleeping in bed (without orthopnea) suggests reduced pulmonary congestion. B, C, E: Edema, weight loss, and high sodium intake do not necessarily indicate improvement.
The nurse is caring for a client who has been ordered a sodium-restricted diet following a myocardial infarction. Which of the following meals would be most appropriate to suggest?
- A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange.
- B. Broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk.
- C. Canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple.
- D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.
Correct Answer: A
Rationale: Fresh foods like turkey, sweet potato, and green beans are low in sodium, unlike canned or processed foods.
Which of the following lifestyle modifications are recommended for managing essential hypertension? Select all that apply.
- A. Isometric exercises
- B. Decreasing sodium intake
- C. Smoking cessation
- D. Use of herbal supplements
- E. Weight loss
Correct Answer: B,C,E
Rationale: Isometric exercises can increase blood pressure and are not recommended. Reducing sodium intake helps lower blood pressure. C: Correct - Smoking cessation reduces cardiovascular risk. D: Incorrect - Herbal supplements are not universally recommended and may interact with medications. E: Correct - Weight loss reduces blood pressure and cardiovascular strain.
The nurse is caring for a client with congestive heart failure experiencing an exacerbation. Which of the following of the client's vital signs would indicate that the client is experiencing a complication?
- A. Decrease in blood pressure
- B. Increase in temperature
- C. Decrease in respiratory rate
- D. Increase in blood pressure
Correct Answer: A
Rationale: A decrease in blood pressure during a CHF exacerbation may indicate cardiogenic shock, a serious complication.
The nurse is reviewing laboratory data for a client suspected of having a myocardial infarction. The nurse anticipates that the CK-MB isoenzyme will peak within how many hours?
- A. 3 to 6 hours
- B. 1 to 2 hours
- C. 48 to 72 hours
- D. 18 hours
Correct Answer: D
Rationale: CK-MB peaks around 18 hours after a myocardial infarction, indicating myocardial damage.