Nokea
The nurse is assessing the client following an inferior-septal wall MI. Which potential complication should the nurse further explore when noting that the client has JVD and ascites?
- A. Left-sided heart failure
- B. Pulmonic valve malfunction
- C. Right-sided heart failure
- D. Ruptured septum
Correct Answer: C
Rationale: Right-sided HF produces venous congestion in the systemic circulation, resulting in JVD and ascites (from vascular congestion in the GI tract). Left-sided HF causes pulmonary congestion, pulmonic valve issues cause murmurs, and a ruptured septum causes shock and murmurs, none of which match the findings.
You may also like to solve these questions
The nurse is caring for the client who had a cardiac valve replacement. To decrease the risk of DVT and PE, which interventions should the nurse plan to include? Select all that apply.
- A. Apply a pneumatic compression device.
- B. Administer a heparin infusion intravenously.
- C. Encourage coughing and deep breathing hourly.
- D. Teach about performing isometric leg exercises.
- E. Avoid the use of graded compression elastic stockings.
Correct Answer: A;D
Rationale: The nurse should include: A) Pneumatic compression devices to mimic walking pressures; D) Isometric exercises to compress vessels and reduce DVT risk. Heparin is typically subcutaneous, coughing/deep breathing prevents pulmonary issues, and compression stockings are beneficial unless PAD is present.
The client calls for the nurse after experiencing sharp chest pains that radiate to the left shoulder. All of the following interventions were prescribed on admission for treating chest pain. Which intervention should the nurse implement first?
- A. STAT 12-lead electrocardiogram (ECG)
- B. Oxygen 4 liters by nasal cannula
- C. Nitroglycerin 0.4 mg sublingual
- D. Morphine sulfate 2-4 mg IV prn
Correct Answer: B
Rationale: Oxygen should be available in the room and should be initiated first to enhance oxygen flow to the myocardium. ECG, nitroglycerin, and morphine are important but secondary to improving oxygenation in acute chest pain.
The nurse reviews symptoms of acute graft occlusion with the client who has had a revascularization graft procedure of the lower extremity. Which symptom of acute arterial occlusion stated by the client indicates the need for further teaching?
- A. Severe pain
- B. Paresthesia
- C. Warm and red incisions
- D. Inability to move the foot
Correct Answer: C
Rationale: Redness and warmth along the incision line are associated with inflammation or infection, not graft occlusion. Severe pain, paresthesia, and inability to move the foot are symptoms of acute arterial occlusion, indicating the client needs further teaching about incision symptoms.
The nurse plans teaching for a 20-year-old newly diagnosed with hypertrophic cardiomyopathy. The client is on the college soccer team. Which information should be the nurse’s priority when teaching the client?
- A. Provide pamphlets on genetic testing to avoid passing on an inherited disease.
- B. Reinforce the need to continue exercise with soccer to strengthen the heart.
- C. Provide information about CPR to persons living with the client.
- D. Counsel on foods for consuming on a low-fat, low-cholesterol diet.
Correct Answer: C
Rationale: Because sudden cardiac death is a large risk factor for those under 30 years of age, the nurse should provide information about having others living with the client trained in CPR as a preventative measure. Genetic testing, continued strenuous exercise, and diet are less immediate priorities.
The client newly diagnosed with HF has an ejection fraction of 20%. Which criteria should the nurse use to evaluate the client’s readiness for discharge to home? Select all that apply.
- A. There is a scale in the client’s home
- B. The client started ambulating 24 hours ago
- C. The client is receiving furosemide IV 20 mg bid
- D. A smoking cessation consult is scheduled for 2 days after discharge
- E. A home-care nurse is scheduled to see the client 3 days after discharge
Correct Answer: A;B;E
Rationale: The nurse should evaluate: A) A scale to monitor fluid status; B) Ambulation to confirm functional capability; E) Home-care nurse visit within 3 days for support. IV furosemide (C) should be oral before discharge, and smoking cessation (D) should start before discharge.