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The nurse is assisting with the care of a client diagnosed with heart failure. Which finding should the nurse report to the healthcare provider immediately?
- A. Weight gain of 2 pounds in 2 days
- B. Increased urination at night
- C. Mild shortness of breath on exertion
- D. Decreased appetite and fatigue
Correct Answer: A
Rationale: A weight gain of 2 pounds in 2 days is concerning in a client with heart failure as it can indicate fluid retention and worsening of the condition. This finding requires immediate medical attention to prevent further complications. Increased urination at night (choice B) may be due to various reasons like diuretic use and is not an immediate concern. Mild shortness of breath on exertion (choice C) is expected in clients with heart failure and may not require immediate reporting. Decreased appetite and fatigue (choice D) are common symptoms in heart failure but are not as urgent as sudden weight gain.
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A client is admitted to the hospital with a diagnosis of myocardial infarction (MI). Which diagnostic test is most likely to be ordered to confirm this diagnosis?
- A. Echocardiogram
- B. Electrocardiogram (ECG)
- C. Chest X-ray
- D. Complete blood count (CBC)
Correct Answer: B
Rationale: An Electrocardiogram (ECG) is the primary diagnostic tool used to confirm a myocardial infarction. An ECG provides immediate information on cardiac function and can show characteristic changes indicative of a myocardial infarction, such as ST-segment elevation or depression. An echocardiogram (Choice A) is useful for assessing heart structure and function but is not typically used as the primary test for confirming an acute myocardial infarction. Chest X-ray (Choice C) may show certain changes in heart size or pulmonary congestion but is not the primary diagnostic test for MI. A Complete Blood Count (CBC) (Choice D) provides information about the cellular components of blood and is not specific to confirming a myocardial infarction.
The nurse is assisting in the care of a client with a history of chronic obstructive pulmonary disease (COPD) who is on oxygen therapy. Which action should the nurse take to ensure the client's safety?
- A. Set the oxygen flow rate to 4 liters per minute.
- B. Remove oxygen while the client is eating.
- C. Ensure the client wears a nasal cannula instead of a face mask.
- D. Maintain the oxygen flow rate at the lowest level that relieves hypoxia.
Correct Answer: D
Rationale: For clients with COPD, too much oxygen can suppress their drive to breathe, leading to hypoventilation. Therefore, the nurse should maintain the oxygen flow rate at the lowest level that relieves hypoxia to prevent complications while ensuring adequate oxygenation. Setting the oxygen flow rate too high (Choice A) can be detrimental for the client with COPD. Removing oxygen while the client is eating (Choice B) can compromise oxygenation, which is essential even during meals. While nasal cannulas are commonly used, the choice of oxygen delivery device depends on the client's needs; there may be situations where a face mask (Choice C) is more appropriate.
The LPN/LVN is reinforcing discharge instructions to a client who has been prescribed nitroglycerin sublingual tablets for angina. Which statement by the client indicates a need for further teaching?
- A. I will keep my nitroglycerin tablets in the original glass bottle.
- B. I will sit or lie down when I take a nitroglycerin tablet.
- C. I will take a nitroglycerin tablet every 5 minutes if chest pain persists, up to a total of 3 tablets.
- D. I can swallow the nitroglycerin tablet with a glass of water if it does not dissolve quickly.
Correct Answer: D
Rationale: The correct answer is D. Nitroglycerin sublingual tablets should not be swallowed; they must dissolve under the tongue to be effective. Choice A is correct as nitroglycerin tablets should be stored in their original glass container to prevent degradation. Choice B is correct as sitting or lying down when taking a nitroglycerin tablet helps prevent dizziness or fainting due to a sudden drop in blood pressure. Choice C is correct as taking a nitroglycerin tablet every 5 minutes for a maximum of 3 tablets is the correct protocol for managing angina symptoms.
A client has a new prescription for propranolol. Which of the following instructions should be included?
- A. Take the medication with food.
- B. Monitor heart rate daily.
- C. Increase intake of potassium-rich foods.
- D. Avoid consuming dairy products.
Correct Answer: B
Rationale: The correct answer is to monitor heart rate daily. Propranolol is a beta-blocker that can lower heart rate and blood pressure, so it is essential to monitor heart rate regularly to detect any signs of bradycardia, a potential side effect of the medication. Choice A is incorrect because propranolol can be taken with or without food. Choice C is incorrect as increasing potassium-rich foods is not specifically required with propranolol. Choice D is also incorrect as there is no need to avoid consuming dairy products with propranolol.
A client with a history of hypertension is being discharged on a low-sodium diet. Which statement by the client indicates a need for further teaching?
- A. I will use fresh herbs and spices instead of salt.
- B. I will avoid canned soups and processed foods.
- C. I can eat as much bacon and sausage as I want because they taste good.
- D. I will read food labels to check for sodium content.
Correct Answer: C
Rationale: Choice C is the correct answer because bacon and sausage are high in sodium, which contradicts the low-sodium diet requirement. Consuming them freely would contribute to increased sodium intake, which is not suitable for managing hypertension. Choices A, B, and D demonstrate appropriate understanding and actions for a low-sodium diet, such as using alternatives to salt, avoiding processed foods, and checking food labels for sodium content.