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The nurse has written an outcome goal 'demonstrates tolerance for increased activity' for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?
- A. Measure intake and output.
- B. Provide two (2)g sodium diet.
- C. Weigh the client daily.
- D. Plan for frequent rest periods.
Correct Answer: D
Rationale: Frequent rest periods (D) prevent overexertion, supporting activity tolerance in CHF. Intake/output (A), sodium diet (B), and daily weights (C) are important but less directly related to activity.
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What is the priority problem in the client diagnosed with congestive heart failure?
- A. Fluid volume overload.
- B. Decreased cardiac output.
- C. Activity intolerance.
- D. Knowledge deficit.
Correct Answer: B
Rationale: Decreased cardiac output (B) is the primary problem in CHF, causing symptoms like fluid overload (A). Activity intolerance (C) and knowledge deficit (D) are secondary.
The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?
- A. Administer sublingual nitroglycerin.
- B. Obtain a STAT electrocardiogram (ECG).
- C. Have the client sit down immediately.
- D. Assess the client's vital signs.
Correct Answer: C
Rationale: Activity-related chest pain suggests ischemia. Having the client sit (C) stops exertion, reducing oxygen demand. Nitroglycerin (A), ECG (B), and vital signs (D) follow.
The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina?
- A. Put a nitroglycerin tablet under the tongue.
- B. Stop the activity immediately and rest.
- C. Document when and what activity caused angina.
- D. Notify the health-care provider immediately.
Correct Answer: B
Rationale: Stopping activity and resting (B) reduces oxygen demand, the first step in angina. Nitroglycerin (A) follows, documenting (C) is later, and notifying HCP (D) is for persistent pain.
The nurse is caring for a client who suddenly complains of crushing substernal chest pain while ambulating in the hall. Which nursing action should the nurse implement first?
- A. Call a Code Blue.
- B. Assess the telemetry reading.
- C. Take the client's apical pulse.
- D. Have the client sit down.
Correct Answer: D
Rationale: Crushing chest pain suggests ischemia; sitting down (D) reduces oxygen demand. Code Blue (A), telemetry (B), and pulse (C) follow if pain persists.
The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the healthcare provider to order for this client?
- A. Amiodarone.
- B. Atropine.
- C. Digoxin.
- D. Adenosine.
Correct Answer: A
Rationale: Amiodarone (A) treats ventricular dysrhythmias like PVCs. Atropine (B) is for bradycardia, digoxin (C) for heart failure/AF, and adenosine (D) for SVT.