Nokea
The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data support this concept?
- A. The client has a large abdomen and a positive tympanic wave.
- B. The client has paroxysmal nocturnal dyspnea.
- C. The client has 2+ glucose in the urine.
- D. The client has a comorbid condition of myocardial infarction.
Correct Answer: B
Rationale: PND (B) indicates fluid overload in CHF, supporting impaired perfusion. Large abdomen (A) suggests ascites, glucosuria (C) is diabetes-related, and MI (D) is a cause, not a symptom.
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During the postoperative period, what is the best rationale for the nurse frequently assessing the client's fluid status?
- A. Urine retention is common after a heart transplant.
- B. Urine output is an indication of perfusion to the kidneys.
- C. Hydration determines when the client needs to be transfused.
- D. Hydration indicates when fluids should be increased.
Correct Answer: B
Rationale: Urine output reflects renal perfusion, critical post-heart transplant to monitor graft function.
The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?
- A. Do you have a daily bowel movement?'
- B. Do you get yearly chest x-rays (CXRs)?'
- C. Are you sexually active?'
- D. Have you had any weight change?'
Correct Answer: D
Rationale: Weight change (D) may indicate fluid retention or malnutrition, relevant to CAD management. Bowel movements (A), CXRs (B), and sexual activity (C) are less directly related.
Which assessment finding best supports the assumption that the client is a good treatment.
- A. Pericardial friction rub
- B. Muffled heart sounds
- C. S3 gallop
- D. Systolic murmur
Correct Answer: A
Rationale: Pericardial friction rub is characteristic of pericarditis due to inflamed pericardial layers.
The nurse counts an adult's apical heart beat at 110 beats per minute. The nurse describes this as:
- A. asystole.
- B. bigeminy.
- C. tachycardia.
- D. bradycardia.
Correct Answer: C
Rationale: Tachycardia in an adult is defined as a heart rate above 100 beats per minute. Asystole is cardiac arrest with no heartbeat. Bigeminy refers to heartbeats occurring in pairs. Bradycardia is a heart rate of 60 beats or less per minute.
A male client with angina pectoris has been having an increased number of episodes of pain recently. He is admitted for observation. During the admission interview, he tells the nurse that he has been having chest pain during the last week. Which statement by the client would be of greatest concern to the nurse?
- A. I had chest pain while I was walking in the snow on Thursday.'
- B. We went out for a big dinner to celebrate my wife's birthday, but I couldn't enjoy it because I got the pain before we got home from the restaurant.'
- C. I had chest pain yesterday while I was sitting in the living room watching television.'
- D. I felt pain all the way down my left arm after I was playing with my grandson on Monday.'
Correct Answer: C
Rationale: Chest pain at rest, such as while watching television, is concerning as it may indicate unstable angina or impending myocardial infarction, requiring urgent evaluation. Pain with activity, eating, or radiating to the arm is typical of angina but less immediately alarming.