Nokea
The nurse assists the code team with an unresponsive and pulseless client. Which intervention does the nurse prepare for based on the electrocardiogram (ECG) tracing? See the image below.
- A. Prepare an infusion of sodium bicarbonate
- B. Administer epinephrine
- C. Defibrillation
- D. Cardioversion
Correct Answer: C
Rationale: Defibrillation is the treatment for pulseless ventricular fibrillation or ventricular tachycardia, per ACLS guidelines.
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History of Present Illness (HPI)
The client was found disoriented upon arrival and in acute respiratory distress.
The client's caregiver noted that the prescribed medications had not been
taken for several days. Medical history includes hypertension, diabetes mellitus,
congestive heart failure, and arthritis. Client Assessment Bounding peripheral pulses,
normotensive, crackles in the lung fields, tachypnea, jugular venous distention, and
abdominal distention.
Diagnosis
1. Pulmonary edema
2. Acute decompensated heart failure
Based on the clinical data, which prescription would the nurse request from the primary healthcare provider for a client with pulmonary edema and acute decompensated heart failure? Select all that apply.
- A. Albuterol
- B. Hydrocortisone
- C. Diltiazem
- D. Nitroglycerin
- E. Furosemide
Correct Answer: D,E
Rationale: Albuterol is for bronchospasm, not pulmonary edema. B: Incorrect - Hydrocortisone is not indicated for heart failure. C: Incorrect - Diltiazem is for rate control, not fluid overload. D: Correct - Nitroglycerin reduces preload, alleviating pulmonary edema. E: Correct - Furosemide is a diuretic to reduce fluid overload.
The nurse is caring for a client and upon initial evaluation the nurse suspects femoral artery occlusion. The nurse should take which action?
- A. Elevate the affected leg
- B. Apply a cold compress
- C. Notify the primary healthcare provider (PHCP)
- D. Perform passive range of motion to the affected leg
Correct Answer: C
Rationale: Femoral artery occlusion is a medical emergency requiring immediate notification of the PHCP for vascular intervention.
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.
Select the six (6) statements that the nurse should include in the teaching plan for a client with heart failure.
- A. You should weigh yourself every morning before breakfast
- B. Report a gain of more than 2 pounds in one day.
- C. It's important to limit your fluid intake to about 3 liters per day.
- D. Try to include potassium-rich foods like bananas and oranges in your diet every day.
- E. Avoid NSAIDs like ibuprofen unless prescribed by your provider.
- F. Take frequent rest periods throughout the day and gradually increase physical activity as tolerated.
- G. Reduce your sodium intake to less than 2,000 mg per day.
Correct Answer: A,B,D,E,F,G
Rationale: Daily weighing monitors fluid status. Weight gain >2 lbs/day indicates fluid retention. C: Incorrect - Fluid restriction is typically 1.5-2 liters/day in heart failure. D: Correct - Potassium-rich foods support electrolyte balance with diuretics. E: Correct - NSAIDs can worsen heart failure. F: Correct - Rest and gradual activity prevent overexertion. G: Correct - Low sodium reduces fluid retention.
The nurse is discharging a client with heart failure who is prescribed digoxin and furosemide. Which of the following laboratory tests must the client have monitored due to this combination of prescribed medications?
- A. Fecal occult blood
- B. Serum electrolytes
- C. Urinalysis
- D. Glycosylated hemoglobin
Correct Answer: B
Rationale: Furosemide can cause hypokalemia, increasing digoxin toxicity risk, so serum electrolytes (especially potassium) must be monitored.
The nurse has instructed a client with hyperlipidemia about self-management. Which statement by the client would require follow-up by the nurse?
- A. I should replace hydrogenated vegetable oils with canola oil when cooking.
- B. I should increase my intake of fish like tuna and salmon more often.
- C. Increasing my fiber intake will help lower my cholesterol.
- D. I am glad that I won't need to reduce red meat from my diet.
Correct Answer: D
Rationale: Red meat is high in saturated fat, which worsens hyperlipidemia. The client needs dietary education.