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The nurse is caring for a client who has been ordered a sodium-restricted diet following a myocardial infarction. Which of the following meals would be most appropriate to suggest?
- A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange.
- B. Broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk.
- C. Canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple.
- D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.
Correct Answer: A
Rationale: Fresh foods like turkey, sweet potato, and green beans are low in sodium, unlike canned or processed foods.
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The nurse is watching the monitor of a client wearing a continuous cardiac monitor when it begins to alarm and fails to display any QRS complexes. Which nursing intervention should the nurse do first?
- A. Press record on the electrocardiogram
- B. Check the client's lead placement
- C. Call the code team
- D. Contact the health care provider
Correct Answer: B
Rationale: Absent QRS complexes may result from loose or disconnected leads, so checking lead placement is the first step.
The nurse is caring for a client newly admitted with infective endocarditis (IE). The nurse should plan for which intervention in the client's care plan?
- A. initiating contact and droplet precautions
- B. obtain a prescription for intravenous antivirals
- C. obtain a prescription for enoxaparin
- D. monitor renal function
Correct Answer: D
Rationale: Infective endocarditis can cause glomerulonephritis, necessitating renal function monitoring (e.g., creatinine levels).
The nurse is caring for a client with the below tracing on the electrocardiogram. The nurse should expect the client to demonstrate which clinical manifestation in conjunction with this electrocardiogram tracing? See the exhibit.
- A. Jugular venous distention (JVD)
- B. Systolic murmur
- C. Irregular pulse
- D. Widened pulse pressure
Correct Answer: C
Rationale: An irregular ECG tracing, such as in atrial fibrillation, typically correlates with an irregular pulse due to inconsistent ventricular contractions.
The nurse is assessing a client with congestive heart failure. Which physical assessment finding should the nurse expect?
- A. Intermittent claudication
- B. S3 gallop
- C. Venous stasis ulcers
- D. Widened pulse pressure
Correct Answer: B
Rationale: An S3 gallop is a common finding in CHF, indicating fluid overload and ventricular dysfunction.
Which of the following interventions should the nurse include when teaching clients strategies for preventing cardiovascular disease? Select all that apply.
- A. Encouraging regular physical exercise
- B. Promoting a diet high in saturated fats
- C. Advising smoking cessation
- D. Recommend no more than 5 alcoholic drinks a day
- E. Educating about the importance of regular blood pressure monitoring
- F. Instructing on the importance of regular cholesterol screenings
Correct Answer: A,C,E,F
Rationale: Regular exercise reduces cardiovascular risk. B: Incorrect - High saturated fat diets increase cardiovascular risk. C: Correct - Smoking cessation lowers cardiovascular disease risk. D: Incorrect - Alcohol should be limited to 1-2 drinks per day for men, 1 for women. E: Correct - Blood pressure monitoring detects hypertension early. F: Correct - Cholesterol screenings identify hyperlipidemia for early intervention.