Nokea
The nurse is performing an assessment on a client with congestive heart failure demonstrating ineffective coping. The nurse should plan to
- A. recommend a support group.
- B. review dietary items low in sodium.
- C. review the client's vaccination status.
- D. recommend the client take St. John's Wort.
Correct Answer: A
Rationale: A support group addresses ineffective coping by providing emotional support and coping strategies.
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The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) is caring for a 41-year-old male client.
Item 1 of 1
Progress Notes
1544: Received client to ICU immediately following percutaneous transluminal coronary angioplasty followed by stenting via right femoral artery. Notified primary health care provider about client status. Awaiting orders.
The nurse contacts the primary healthcare provider for admission orders
For each potential order, click to specify whether the potential order is indicated or not indicated for the client post-percutaneous transluminal coronary angioplasty.
- A. Head of the bed elevated up to 30 degrees
- B. Elevate the right leg on a pillow
- C. Continuous cardiac monitoring
- D. Serial troponin levels
- E. Keep the client NPO
- F. Obtain serum glucose levels every two hours
Correct Answer: A,C,D,F
Rationale: A: Indicated - Elevating the head of the bed promotes comfort and reduces cardiac workload. B: Not indicated - Elevating the leg is not standard post-angioplasty unless specified for complications. C: Indicated - Continuous monitoring detects arrhythmias post-procedure. D: Indicated - Serial troponin levels monitor for myocardial injury. E: Not indicated - NPO status is typically temporary and not required post-procedure unless specified. F: Indicated - Glucose monitoring is crucial for diabetic patients or those at risk post-procedure.
The nurse is preparing a client for a scheduled percutaneous coronary intervention (PCI). Which statement made by the client should be reported to the primary healthcare provider (PHCP)
- A. I took my metformin this morning.
- B. I get anxious when I am in closed spaces.
- C. I am allergic to shellfish.
- D. I may feel a warm sensation during the procedure.
Correct Answer: C
Rationale: Shellfish allergy may indicate iodine sensitivity, relevant for contrast dye used in PCI, requiring PHCP notification.
The nurse is caring for a client with myocardial infarction (MI), who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following?
- A. Observe for neurological changes
- B. Monitor for any signs of renal failure
- C. Observe for signs of bleeding
- D. Check the client's food diary
Correct Answer: C
Rationale: tPA is a thrombolytic that increases bleeding risk. Monitoring for signs of bleeding (e.g., hematoma, gastrointestinal bleeding) is critical.
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
Correct Answer: A
Rationale: Right-sided heart failure causes systemic congestion, leading to ascites due to fluid accumulation in the abdomen.
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
Correct Answer: A,B,C,D,E,F,G
Rationale: All findings indicate worsening heart failure: A, B, C, G - Shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea suggest pulmonary congestion. D: Weight gain indicates fluid retention. E: Accessory muscle use shows respiratory distress. F: Crackles indicate pulmonary edema.