Nokea
The nurse is assessing the client. At which area should the nurse place the stethoscope to best auscultate the client’s murmur associated with mitral regurgitation?
- A. Line A
- B. Line B
- C. Line C
- D. Line D
Correct Answer: D
Rationale: Mitral regurgitation is heard at the location of the mitral valve (line D) and should be auscultated with the bell of the stethoscope at the fifth intercostal space, left midclavicular line. The bell is used to auscultate low-pitched sounds. Lines A, B, and C correspond to aortic, pulmonic, and tricuspid valves, respectively.
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The client’s BP is being taken at a screening clinic. Which client statement to the nurse demonstrates awareness of having a risk factor for hypertension?
- A. “My doctor told me my body mass index is 23 and my blood pressure is 118/70.”
- B. “I usually have a glass of wine to unwind when I come home from work.”
- C. “I plan to get my blood pressure checked more often, as I am African American.”
- D. “I have colds during the winter, so I plan to get the influenza vaccine every year.”
Correct Answer: C
Rationale: Being African American is a known risk factor for hypertension. Starting to have the BP taken more often demonstrates awareness of having a risk factor for hypertension. A BMI of 23 is normal, excessive alcohol intake increases risk but one glass is not excessive, and colds or flu vaccines do not directly relate to hypertension risk.
The nurse, assessing the client hospitalized following an MI, obtains these VS: BP 78/38 mm Hg, HR 128, RR 32. The nurse notifies the HCP concerned that the client may be experiencing which most life-threatening complication?
- A. Pulmonary embolism
- B. Cardiac tamponade
- C. Cardiomyopathy
- D. Cardiogenic shock
Correct Answer: D
Rationale: The symptoms are indicative of cardiogenic shock (decreased cardiac output leading to inadequate tissue perfusion and initiation of the shock syndrome). Pulmonary embolism and tamponade could cause shock but are less likely post-MI, and cardiomyopathy is not an acute complication.
While preparing the client for a computed tomography angiography (CTA), the client asks the nurse what the test Will entail. Which should be the nurse’s correct response?
- A. “A CTA uses magnetic fields to visualize the major vessels Within your body.”
- B. “A CTA is an invasive procedure that requires a small incision into an artery.”
- C. “A CTA is a quick procedure that requires anesthesia for about 20 minutes.”
- D. “A CTA is a scan that includes a contrast dye injection to visualize your arteries.”
Correct Answer: D
Rationale: The correct response should explain CTA. CTA is a noninvasive spiral CT scan using contrast dye to yield a 3-dimensional image of the arteries. It does not use magnetic fields (A), require incisions (B), or anesthesia (C).
The client with class II HF according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes which component?
- A. Diuretics
- B. A low-sodium diet
- C. Home oxygen therapy
- D. Angiotensin-converting enzyme (ACE) inhibitors
Correct Answer: C
Rationale: In class II HF, normal physical activity results in fatigue, dyspnea, palpitations, or anginal pain, but symptoms are absent at rest. Home oxygen therapy is unnecessary unless there are other comorbid conditions. Diuretics, low-sodium diet, and ACE inhibitors are standard treatments.
The nurse is discussing healthy lifestyle practices with the client who has chronic venous insufficiency. Which practices should be emphasized with this client? Select all that apply.
- A. Avoid eating an excess of dark green vegetables.
- B. Take rests and elevate the legs while sitting.
- C. Wear graduated compression stockings, removing them at night.
- D. Increase standing time and shift weight when upright.
- E. Sleep with legs elevated above the level of the heart.
Correct Answer: B;C;E
Rationale: The nurse should emphasize: B) Elevating legs when sitting to promote venous return; C) Wearing compression stockings to reduce edema; E) Sleeping with legs elevated to enhance venous return. Avoiding dark green vegetables is relevant only with anticoagulants, and prolonged standing should be avoided.