Nokea
The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
- A. Right-sided heart failure.
- B. Left ventricular dysfunction.
- C. Cardiac tamponade.
- D. Internal bleeding.
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to edema, jugular distention, and elevated central venous pressure.
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The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Remain upright following meals.
- B. Avoid wearing tight fitting clothes.
- C. Minimize intake of spicy foods.
- D. Begin a smoking cessation program.
Correct Answer: A
Rationale: Remaining upright prevents gastric reflux by aiding stomach emptying, directly addressing GERD symptoms.
Nurses' Notes
Physical Examination
Vital Signs
Day 1, 0830
Body mass index (BMI) is 31.8 kg/m2
Pain rating of 8 on 0 to 10 scale, in the right foot
Client history has been collected, and the nurse performs a physical assessment and records vital signs
Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
- A. Drinks beer nightly
- B. Hypertension
- C. Sleep apnea
- D. Ibuprofen for pain
- E. Daily aspirin
- F. Type 2 diabetes mellitus
- G. osteoarthritis
Correct Answer: A,B,F,G
Rationale: Beer , hypertension , diabetes, osteoarthritis increase uric acid levels or metabolic risks for gout.
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client's blood pressure reading will be less than 160/90 mm Hg.
- B. The client's daily blood pressure will be less than 140/80 mm Hg this month.
- C. The client's family will repeat signs and symptoms about the disease.
- D. The nurse will encourage the client to walk thirty minutes every day.
Correct Answer: B
Rationale: A blood pressure goal of less than 140/80 mm Hg is specific and aligns with cardiovascular health targets, addressing blurred vision linked to hypertension.
A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?
- A. Use a space heater to keep the workspace warm.
- B. Take a multivitamin that contains vitamin D daily.
- C. Keep both hands elevated during work breaks.
- D. Obtain a keyboard designed to limit wrist flexion.
Correct Answer: A
Rationale: A warm workspace prevents vasospasm, reducing Raynaud's attacks during work.
Orders
Laboratory Results
Day 1, 1000
Serum uric acid, blood urea nitrogen (BUN), creatinine (Cr)
X-ray of right foot
Day 1, 1015
Acetaminophen 650 mg PO now
Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for SwellingBruisingInfectionInflammationRash and DiscolorationErythemaCyanosisPallorEcchymosis in his affected joint.
- A. Inflammation
- B. Discoloration
- C. Erythema Cyanosis
- D. Swelling
- E. Bruising
Correct Answer: A,B
Rationale: Inflammation and discoloration are hallmark symptoms of gout due to urate crystal-induced immune response and increased blood flow.