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The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure?
- A. ascites
- B. tachypnea
- C. cough
- D. orthopnea
Correct Answer: A
Rationale: Right-sided heart failure causes systemic congestion, leading to ascites due to fluid accumulation in the abdomen.
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Which of the following heart sounds would the nurse expect to auscultate in a client with systolic heart failure? Select all that apply.
- A. S1
- B. S2
- C. S3
- D. S4
- E. Pleural friction rub
Correct Answer: C
Rationale: S1 is a normal heart sound. B: Incorrect - S2 is a normal heart sound. C: Correct - S3 is associated with systolic heart failure due to rapid ventricular filling. D: Incorrect - S4 is linked to diastolic dysfunction, not systolic failure. E: Incorrect - Pleural friction rub indicates pleural inflammation, not heart failure.
The nurse is assessing a client's cardiac rhythm strip and notices that it is irregular without any P waves before the QRS complexes. The nurse should interpret this as
- A. sinus tachycardia.
- B. sinus bradycardia.
- C. normal sinus rhythm with premature ventricular contractions (PVC).
- D. atrial fibrillation
Correct Answer: D
Rationale: Atrial fibrillation is characterized by an irregular rhythm and absent P waves due to chaotic atrial activity.
The nurse is caring for a client who has just been diagnosed with acute pericarditis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe?
- A. isoniazid
- B. colchicine
- C. allopurinol
- D. warfarin
Correct Answer: B
Rationale: Colchicine is used to reduce inflammation in acute pericarditis, often combined with NSAIDs.
The nurse is caring for a client following a femoral angiography. When developing this client's plan of care, the nurse plans to
- A. encourage the client to ambulate within one hour following this procedure.
- B. discontinue prescribed intravenous fluids immediately after the procedure
- C. assess kidney function via lab testing on the day following the procedure.
- D. maintain nothing by mouth (NPO) status for 4 hours following the procedure.
Correct Answer: C
Rationale: Femoral angiography involves contrast dye, which can affect kidney function. Monitoring renal function via lab tests (e.g., creatinine) post-procedure is essential to detect contrast-induced nephropathy.
Which of the following interventions should the nurse implement to manage fluid volume overload in a client with heart failure? Select all that apply.
- A. Administer diuretics as prescribed
- B. Monitor daily weights
- C. Restrict fluid intake to 500 mL per day
- D. Assess lung sounds for crackles
- E. Encourage high-sodium diet
- F. Assess lung sounds for rhonchi
Correct Answer: A,B,D
Rationale: Diuretics reduce fluid overload. Daily weights monitor fluid status. C: Incorrect - 500 mL/day is too restrictive; 1.5-2 L is typical. D: Correct - Crackles indicate pulmonary edema. E: Incorrect - High-sodium diets worsen fluid retention. F: Incorrect - Rhonchi are not specific to fluid overload.