Exam for RN Cardiovascular NCLEX Exam Related

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.

Which findings suggest a worsening of the client's condition and warrant follow-up by the nurse for a client presenting with shortness of breath and heart failure? Select all that apply.

• A. Describes increasing shortness of breath over the past 2 days
• B. States, 'I feel like I can't catch my breath'
• C. Mentions needing to sleep in a recliner to breathe comfortably
• D. Notes a 4-pound weight gain over the past week
• E. Exhibiting use of accessory muscles during respiration
• F. Auscultation reveals bilateral crackles in the lungs
• G. Reports orthopnea and episodes of paroxysmal nocturnal dyspnea

The emergency department nurse is caring for a client with congestive heart failure who reports dyspnea and a persistent cough. The nurse obtains the client's vital signs and suspects that the client is experiencing which condition? See the image below.

• A. Pulmonary embolism
• B. Hypovolemic shock
• C. Disseminated intravascular coagulation (DIC)
• D. Pulmonary edema

Which of the following information should the nurse include when teaching a client about congestive heart failure (CHF)? Select all that apply.

• A. Foods such as canned vegetables and luncheon meat should be avoided.
• B. Weigh yourself daily and notify the physician if the weight gain is more than ten pounds in a week.
• C. You may continue to take ibuprofen for your aches and pains.
• D. Annual immunizations such as the influenza vaccine are recommended.
• E. If you feel sick, you will need to check your urine for ketones.

The nurse cares for a client with the below tracing on the electrocardiogram. The client is unresponsive and without a pulse. The nurse should implement which priority treatment based on the tracing

• A. Start cardiopulmonary resuscitation (CPR)
• B. Perform immediate defibrillation
• C. Initiate intravenous (IV) access
• D. Review the client's most recent electrolyte levels

The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure?

• A. ascites
• B. tachypnea
• C. cough
• D. orthopnea