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The nurse is assessing a client with congestive heart failure. Which physical assessment finding should the nurse expect?
- A. Intermittent claudication
- B. S3 gallop
- C. Venous stasis ulcers
- D. Widened pulse pressure
Correct Answer: B
Rationale: An S3 gallop is a common finding in CHF, indicating fluid overload and ventricular dysfunction.
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The nurse caring for a client with a history of atrial fibrillation is prescribed dofetilide to control the dysrhythmia. What assessment should the nurse prioritize before administering the medication?
- A. Daily weight
- B. Liver function tests
- C. QT interval on the electrocardiogram (ECG)
- D. Blood urea nitrogen (BUN) and creatinine levels
Correct Answer: C
Rationale: Dofetilide can prolong the QT interval, increasing the risk of torsades de pointes, so monitoring the ECG for QT prolongation is critical.
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.
The nurse assesses a client with acute left leg swelling and calf tenderness following a long car ride. The nurse anticipates that the primary healthcare provider (PHCP) will order which diagnostic test?
- A. D-dimer test
- B. Ankle-Brachial Index
- C. Radiograph (X-Ray)
- D. Venous Duplex Ultrasonography
Correct Answer: D
Rationale: Venous duplex ultrasonography is the gold standard for diagnosing deep vein thrombosis, indicated by swelling and tenderness.
The nurse reviews a client's lipid panel who is being treated for hyperlipidemia with simvastatin. Which of the following actions should the nurse take based on the results? See the results in the exhibit.
- A. Review the client's most recent creatinine
- B. Assess the client's adherence to the prescribed medication
- C. Determine if the client is adhering to a low salt diet
- D. Document the results as within normal limits
Correct Answer: B
Rationale: If lipid panel results are abnormal, assessing adherence to simvastatin is key, as non-compliance may explain ineffective treatment.
The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). The client reports dyspnea and dizziness. The nurse should obtain a prescription for which medication? See the image below.
- A. Diltiazem
- B. Amiodarone
- C. Labetalol
- D. Atropine
Correct Answer: B
Rationale: Amiodarone is used for ventricular arrhythmias (e.g., ventricular tachycardia), which may cause dyspnea and dizziness.