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The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?
- A. An elevated B-type natriuretic peptide (BNP).
- B. An elevated creatine kinase (CK-MB).
- C. A positive D-dimer.
- D. A positive ventilation/perfusion (V/Q) scan.
Correct Answer: A
Rationale: Elevated BNP (A) is specific to heart failure, reflecting ventricular stress. CK-MB (B) indicates myocardial infarction, D-dimer (C) suggests clotting, and V/Q scan (D) is for pulmonary embolism.
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The client with coronary artery disease is prescribed transdermal nitroglycerin, a coronary vasodilator. Which behavior indicates the client understands the discharge teaching concerning this medication?
- A. The client places the medication under the tongue.
- B. The client removes the old patch before placing the new.
- C. The client applies the patch to a hairy area.
- D. The client changes the patch every 36 hours.
Correct Answer: B
Rationale: Removing the old patch (B) ensures proper dosing and prevents overdose. Sublingual (A) is incorrect, hairy areas (C) reduce adhesion, and patches are changed every 24 hours (D).
Which client problem has priority for the client with a cardiac dysrhythmia?
- A. Alteration in comfort.
- B. Decreased cardiac output.
- C. Impaired gas exchange.
- D. Activity intolerance.
Correct Answer: B
Rationale: Dysrhythmias primarily reduce cardiac output (B), impacting perfusion, making it the priority. Comfort (A), gas exchange (C), and activity (D) are secondary.
The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis?
- A. Have you had a sore throat in the last month?'
- B. Did you have rheumatic fever as a child?'
- C. Do you have a family history of carditis?'
- D. What over-the-counter (OTC) medications do you take?'
Correct Answer: B
Rationale: Rheumatic fever (B) is a major cause of carditis, especially in children, making it the most relevant question. Sore throat (A) is less specific, family history (C) is rare, and OTC meds (D) are unrelated.
The nurse is caring for a client who suddenly complains of crushing substernal chest pain while ambulating in the hall. Which nursing action should the nurse implement first?
- A. Call a Code Blue.
- B. Assess the telemetry reading.
- C. Take the client's apical pulse.
- D. Have the client sit down.
Correct Answer: D
Rationale: Crushing chest pain suggests ischemia; sitting down (D) reduces oxygen demand. Code Blue (A), telemetry (B), and pulse (C) follow if pain persists.
The client with infective endocarditis is admitted to the medical department. Which health-care provider’s order should be implemented first?
- A. Administer intravenous antibiotic.
- B. Obtain blood cultures times two (2).
- C. Schedule an echocardiogram.
- D. Encourage bedrest with bathroom privileges.
Correct Answer: B
Rationale: Blood cultures (B) are obtained first in endocarditis to identify the pathogen before antibiotics (A) obscure results. Echocardiogram (C) and bedrest (D) follow.