Nokea
The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of 'decreased cardiac output related to inability of the heart to pump effectively' is written. Which short-term goal would be best for the client?
- A. The client will be able to ambulate in the hall by date of discharge.
- B. The client will have an audible S1 and S2 with no S3 heard by end of shift.
- C. The client will turn, cough, and deep breathe every two (2) hours.
- D. The client will have a SaO2 reading of 98% by day two (2) of care.
Correct Answer: B
Rationale: Absence of an S3 heart sound (B) indicates improved cardiac function, directly addressing decreased cardiac output. Ambulation (A) is long-term, turning/coughing (C) is an intervention, and SaO2 of 98% (D) is less specific to cardiac output.
You may also like to solve these questions
The nurse is caring for a client diagnosed with coronary artery disease (CAD). Which should the nurse teach the client prior to discharge?
- A. Carry your nitroglycerin tablets in a brown bottle.
- B. Swallow a nitroglycerin tablet at the first sign of angina.
- C. If one nitroglycerin tablet does not work in 10 minutes, take another.
- D. Nitroglycerin tablets have a fruity odor if they are potent.
Correct Answer: A
Rationale: Nitroglycerin should be stored in a dark bottle (A) to maintain potency. Swallowing (B) is incorrect (sublingual), 10 minutes (C) should be 5, and fruity odor (D) is not a potency indicator.
The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement?
- A. Perform isometric exercises daily.
- B. Walk for 15 minutes three (3) times a week.
- C. Do not walk outside if it is less than 40°F.
- D. Wear open-toed shoes when ambulating.
Correct Answer: B
Rationale: Walking 15 minutes 3 times a week (B) is a safe, aerobic exercise for CAD. Isometric exercises (A) increase BP, cold weather (C) is a precaution, and open-toed shoes (D) are irrelevant.
Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency?
- A. A loud S1, S2 split, and a mitral opening snap.
- B. A holosystolic murmur heard best at the cardiac apex.
- C. A midsystolic ejection click or murmur heard at the base.
- D. A high-pitched sound heard at the third left intercostal space.
Correct Answer: B
Rationale: Mitral insufficiency (regurgitation) causes a holosystolic murmur at the apex (B) due to backflow. S1/S2 snap (A) is mitral stenosis, ejection click (C) is aortic/pulmonic, and high-pitched sound (D) is nonspecific.
The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the Post Anesthesia Care Unit nurse implement?
- A. Assess the client's chest tube output.
- B. Monitor the client's chest dressing.
- C. Evaluate the client's endotracheal (ET) lip line.
- D. Keep the client's affected leg straight.
Correct Answer: D
Rationale: Valvuloplasty is performed via femoral access, so keeping the leg straight (D) prevents bleeding. Chest tubes (A), dressings (B), and ET tubes (C) are not involved.
The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?
- A. Social worker.
- B. Physical therapy.
- C. Cardiac rehabilitation.
- D. Occupational therapy.
Correct Answer: C
Rationale: Cardiac rehabilitation (C) promotes recovery through exercise and education post-MI. Social work (A), physical therapy (B), and occupational therapy (D) are less specific.