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The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
- A. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
- B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
- C. Instruct the client to remove the saltshaker from the dinner table.
- D. Encourage the client to monitor urine output for change in color to become dark.
- E. Discuss the importance of taking the loop diuretic furosemide at bedtime.
Correct Answer: A,B,C
Rationale: Weight gain monitoring (A) detects fluid retention, pulse counting (B) ensures digoxin safety, and removing salt (C) reduces sodium intake. Dark urine (D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.
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The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina?
- A. Put a nitroglycerin tablet under the tongue.
- B. Stop the activity immediately and rest.
- C. Document when and what activity caused angina.
- D. Notify the health-care provider immediately.
Correct Answer: B
Rationale: Stopping activity and resting (B) reduces oxygen demand, the first step in angina. Nitroglycerin (A) follows, documenting (C) is later, and notifying HCP (D) is for persistent pain.
The client with infective endocarditis is admitted to the medical department. Which health-care provider’s order should be implemented first?
- A. Administer intravenous antibiotic.
- B. Obtain blood cultures times two (2).
- C. Schedule an echocardiogram.
- D. Encourage bedrest with bathroom privileges.
Correct Answer: B
Rationale: Blood cultures (B) are obtained first in endocarditis to identify the pathogen before antibiotics (A) obscure results. Echocardiogram (C) and bedrest (D) follow.
The nurse identifies the concept of altered tissue perfusion related to a client admitted with atrial fibrillation. Which interventions should the nurse implement? Select all that apply.
- A. Monitor the client's blood pressure and apical rate every four (4) hours.
- B. Place the client on intake and output every shift.
- C. Require the client to sleep with the head of the bed elevated.
- D. Teach the patient to perform Buerger Allen exercises daily.
- E. Determine if the client is on an antiplatelet or anticoagulant medication.
- F. Assess the client's neurological status every shift and prn.
Correct Answer: A,E,F
Rationale: Monitoring BP/apical rate (A), anticoagulation status (E), and neurological status (F) address AF-related perfusion risks (clots, stroke). I/O (B) is for fluid status, HOB elevation (C) is for CHF, and Buerger Allen (D) is for PAD.
The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first?
- A. Tell the UAP to go take the client's vital signs.
- B. Ask the UAP to have the telemetry nurse read the strip.
- C. Notify the client's health-care provider.
- D. Go to the room and assess the client's chest pain.
Correct Answer: D
Rationale: Chest pain in CAD requires immediate nurse assessment (D) to determine severity and cause. Vital signs (A), telemetry (B), and notifying HCP (C) follow assessment.
What is the priority problem in the client diagnosed with congestive heart failure?
- A. Fluid volume overload.
- B. Decreased cardiac output.
- C. Activity intolerance.
- D. Knowledge deficit.
Correct Answer: B
Rationale: Decreased cardiac output (B) is the primary problem in CHF, causing symptoms like fluid overload (A). Activity intolerance (C) and knowledge deficit (D) are secondary.