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The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?
- A. The client's peripheral pitting edema has gone from 3+ to 4+.
- B. The client is able to take the radial pulse accurately.
- C. The client is able to perform ADLs without dyspnea.
- D. The client has minimal jugular vein distention.
Correct Answer: C,D
Rationale: Effective CHF treatment reduces fluid overload, allowing ADLs without dyspnea (C) and minimal JVD (D). Increased edema (A) indicates worsening, and pulse-taking (B) is a skill, not a treatment outcome.
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The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the Post Anesthesia Care Unit nurse implement?
- A. Assess the client's chest tube output.
- B. Monitor the client's chest dressing.
- C. Evaluate the client's endotracheal (ET) lip line.
- D. Keep the client's affected leg straight.
Correct Answer: D
Rationale: Valvuloplasty is performed via femoral access, so keeping the leg straight (D) prevents bleeding. Chest tubes (A), dressings (B), and ET tubes (C) are not involved.
The client comes to the emergency department saying, 'I am having a heart attack.' Which question is most pertinent when assessing the client?
- A. Can you describe your chest pain?'
- B. What were you doing when the pain started?'
- C. Did you have a high-fat meal today?'
- D. Does the pain get worse when you lie down?'
Correct Answer: A
Rationale: Describing chest pain (A) is most pertinent to differentiate cardiac from non-cardiac causes. Activity (B), diet (C), and positional pain (D) are secondary.
Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?
- A. Midepigastric pain and pyrosis.
- B. Diaphoresis and cool, clammy skin.
- C. Intermittent claudication and pallor.
- D. Jugular vein distention and dependent edema.
Correct Answer: B
Rationale: MI causes diaphoresis and cool, clammy skin (B) due to sympathetic activation. Epigastric pain/pyrosis (A) suggest GI issues, claudication/pallor (C) indicate PAD, and JVD/edema (D) suggest heart failure.
The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply.
- A. Monitor vital signs every 15 minutes for the first hour.
- B. Assess the client's heart and lung sounds.
- C. Record the amount of fluid removed as output.
- D. Evaluate the client's cardiac rhythm.
- E. Keep the client in the supine position.
Correct Answer: A,B,C,D
Rationale: Post-pericardiocentesis, monitor vital signs (A), heart/lung sounds (B), fluid output (C), and rhythm (D) to detect complications. Supine position (E) is not required; semi-Fowler’s is preferred.
The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in one (1) minute.
- B. The client diagnosed with coronary artery disease who wants to ambulate.
- C. The client diagnosed with mitral valve prolapse with an audible S3.
- D. The client diagnosed with pericarditis who is in normal sinus rhythm.
Correct Answer: C
Rationale: An S3 in mitral valve prolapse (C) suggests heart failure, requiring immediate assessment. Unifocal PVCs (A) are less urgent, ambulation (B) is routine, and normal rhythm in pericarditis (D) is stable.