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The nurse is caring for a client with a myocardial infarction experiencing tachycardia and coughing up frothy, pink-tinged sputum. Which finding would the nurse expect upon lung auscultation?
- A. Wheezing
- B. Crackles
- C. Rhonchi
- D. Diminished sounds
Correct Answer: B
Rationale: Frothy, pink-tinged sputum indicates pulmonary edema, often post-MI, causing crackles on lung auscultation due to fluid in alveoli.
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The nurse is caring for a client with cardiac tamponade. Which vital signs are expected?
- A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg
- B. HR: 90 bpm; RR: 32; BP: 90/52 mmHg
- C. HR: 115 bpm; RR: 22; BP: 140/78 mmHg
- D. HR: 54 bpm; RR: 14; BP: 161/52 mmHg
Correct Answer: A
Rationale: Cardiac tamponade causes tachycardia (HR >100), increased respiratory rate, and hypotension due to restricted cardiac output.
Which interventions would be appropriate for a client with decreased cardiac output? Select all that apply.
- A. Apply compression stockings
- B. Obtain a prescription for nitroglycerin via transdermal patch
- C. Elevate the client's legs
- D. Implement fall precautions
- E. Educate the client about not straining when defecating
Correct Answer: A,D,E
Rationale: Compression stockings improve venous return, supporting cardiac output. B: Incorrect - Nitroglycerin reduces preload, potentially worsening cardiac output in some cases. C: Incorrect - Leg elevation is not standard for low cardiac output and may worsen symptoms. D: Correct - Fall precautions are needed due to potential weakness or syncope. E: Correct - Avoiding straining prevents Valsalva maneuver, which can reduce cardiac output.
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.
The nurse knows that the priority concept associated with the client's condition is ………….caused by a reduction in…………
- A. Oxygenation
- B. Perfusion
- C. Gas exchange
- D. Cardiac output
- E. Hemoglobin concentration
- F. Fluid balance
Correct Answer: B,D
Rationale: Heart failure is primarily a condition of reduced perfusion (B) due to decreased cardiac output (D), impairing the heart's ability to pump blood effectively.
A client admitted due to emergent hypertension is about to be discharged. The nurse is giving instructions about dietary modifications. Which food choice by the client would indicate an accurate understanding of a low fat, low cholesterol diet?
- A. Macaroni and cheese
- B. Fish and chips
- C. Turkey breast salad
- D. Pepperoni pizza
Correct Answer: C
Rationale: Turkey breast salad is low in fat and cholesterol, suitable for a heart-healthy diet, unlike the other high-fat options.
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.