Nokea
The nurse is caring for a client and upon initial evaluation the nurse suspects femoral artery occlusion. The nurse should take which action?
- A. Elevate the affected leg
- B. Apply a cold compress
- C. Notify the primary healthcare provider (PHCP)
- D. Perform passive range of motion to the affected leg
Correct Answer: C
Rationale: Femoral artery occlusion is a medical emergency requiring immediate notification of the PHCP for vascular intervention.
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The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis?
- A. Basic metabolic panel (BMP)
- B. B-type natriuretic peptide (BNP)
- C. Lipid profile
- D. Troponin
Correct Answer: B
Rationale: BNP is a specific biomarker elevated in heart failure, reflecting ventricular stress and fluid overload.
Which of the following findings would support a diagnosis of acute myocardial infarction (AMI)? Select all that apply.
- A. Dizziness
- B. Hypotension
- C. Orthopnea
- D. Nausea
- E. Polyuria
- F. Pulsus paradoxus
Correct Answer: A,B,D
Rationale: Dizziness can result from reduced cardiac output in AMI. Hypotension may occur due to impaired cardiac function. C: Incorrect - Orthopnea is more typical of heart failure. D: Correct - Nausea is a common symptom of AMI. E: Incorrect - Polyuria is not associated with AMI. F: Incorrect - Pulsus paradoxus is linked to pericardial conditions like tamponade.
The following scenario applies to the next 6 items
The client is a 72-year-old male who presents to the emergency department with increasing
shortness of breath over the past two days that gets worse when he is lying flat in bed at night.
Item 1 of 6
History And Physical Nurses' Notes Flow Sheet
0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The
the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
Select the six (6) statements that the nurse should include in the teaching plan for a client with heart failure.
- A. You should weigh yourself every morning before breakfast
- B. Report a gain of more than 2 pounds in one day.
- C. It's important to limit your fluid intake to about 3 liters per day.
- D. Try to include potassium-rich foods like bananas and oranges in your diet every day.
- E. Avoid NSAIDs like ibuprofen unless prescribed by your provider.
- F. Take frequent rest periods throughout the day and gradually increase physical activity as tolerated.
- G. Reduce your sodium intake to less than 2,000 mg per day.
Correct Answer: A,B,D,E,F,G
Rationale: Daily weighing monitors fluid status. Weight gain >2 lbs/day indicates fluid retention. C: Incorrect - Fluid restriction is typically 1.5-2 liters/day in heart failure. D: Correct - Potassium-rich foods support electrolyte balance with diuretics. E: Correct - NSAIDs can worsen heart failure. F: Correct - Rest and gradual activity prevent overexertion. G: Correct - Low sodium reduces fluid retention.
Which of the following findings would the nurse expect to observe in a client who has developed cardiac tamponade? Select all that apply.
- A. Unilateral crackles
- B. Systolic murmur
- C. Bradycardia
- D. Jugular venous distention
- E. Hypotension
Correct Answer: D,E
Rationale: Unilateral crackles suggest pulmonary issues, not tamponade. B: Incorrect - Systolic murmur is not specific to tamponade. C: Incorrect - Tachycardia, not bradycardia, is typical in tamponade due to compensatory mechanisms. D: Correct - Jugular venous distention occurs due to increased venous pressure. E: Correct - Hypotension results from reduced cardiac output in tamponade.
The nurse is discharging a client with heart failure who is prescribed digoxin and furosemide. Which of the following laboratory tests must the client have monitored due to this combination of prescribed medications?
- A. Fecal occult blood
- B. Serum electrolytes
- C. Urinalysis
- D. Glycosylated hemoglobin
Correct Answer: B
Rationale: Furosemide can cause hypokalemia, increasing digoxin toxicity risk, so serum electrolytes (especially potassium) must be monitored.