Nokea
The nurse is assessing a client with clinical manifestations of right ventricular heart failure (HF). Which of the following statements by the client would be consistent with this diagnosis?
- A. I notice that my feet are always swollen.
- B. I can't seem to get rid of this wet cough.
- C. I develop shortness of breath after I walk a few feet.
- D. My legs start to burn if I walk long distances.
Correct Answer: A
Rationale: Right ventricular heart failure causes systemic venous congestion, leading to peripheral edema, such as swollen feet.
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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.
For each medication, choose the most likely option for drug classification and mechanism of action for heart failure: Spironolactone, Sacubitril/Valsartan, Dapagliflozin
- A. Spironolactone: MRA, Blocks aldosterone effects
- B. Sacubitril/Valsartan: ARNI, Blocks RAAS and neprilysin
- C. Dapagliflozin: SGLT2 inhibitor, Causes osmotic diuresis
Correct Answer: A,B,C
Rationale: Spironolactone: MRA (Mineralocorticoid Receptor Antagonist) blocks aldosterone, reducing fluid retention. Sacubitril/Valsartan: ARNI blocks RAAS and neprilysin, improving vasodilation and diuresis. Dapagliflozin: SGLT2 inhibitor causes osmotic diuresis, reducing fluid overload.
The nurse is caring for a client receiving a continuous infusion of diltiazem who has the below tracing on the electrocardiogram (ECG). On assessment, the client has irregular peripheral pulses, an S3 heart sound, and 2+ pedal edema. The nurse should plan to take which priority action? See the image below.
- A. Assess the client for chest pain
- B. Perform a 12-lead electrocardiogram
- C. Stop the infusion
- D. Obtain an immediate troponin level
Correct Answer: C
Rationale: S3 and edema suggest heart failure, possibly exacerbated by diltiazem's negative inotropic effect. Stopping the infusion is the priority.
The nurse is assisting a physician in performing a bronchoscopy. The nurse suspects the client is experiencing a vasovagal response as evidence by the client's
- A. hypertension.
- B. bronchodilation.
- C. increase in heart rate (HR).
- D. decrease in heart rate (HR).
Correct Answer: D
Rationale: A vasovagal response causes bradycardia due to vagal nerve stimulation during procedures like bronchoscopy.
The nurse is caring for a client with the following tracing on the electrocardiogram. When reviewing the client's medical history, which condition could be causing this dysrhythmia? See the image below.
- A. Graves' disease
- B. Increased intracranial pressure
- C. Severe hypothermia
- D. Myxedema coma
Correct Answer: C
Rationale: Severe hypothermia can cause bradycardia or ventricular arrhythmias, such as Osborne waves, on ECG.
The nurse observes the following tracing on the telemetry monitor. The nurse should take which initial action? See the image below.
- A. Assess the client's level of consciousness
- B. Prepare the client for immediate defibrillation
- C. Administer a dose of intravenous epinephrine
- D. Evaluate the client's cardiac lead placement
Correct Answer: B
Rationale: A life-threatening rhythm like ventricular fibrillation requires immediate defibrillation to restore normal rhythm.