Nokea
The nurse performs a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened non-tender maculae on the hands and feet. The nurse understands that these are
- A. Heberden's nodes
- B. Janeway lesions
- C. Tophi
- D. Bouchard's nodes
Correct Answer: B
Rationale: Janeway lesions are non-tender, erythematous maculae on the palms and soles, characteristic of infective endocarditis.
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The nurse is caring for a client recovering from myocardial infarction who is presenting with a heart rate of 110 beats per minute, a blood pressure of 86/58 mmHg, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority?
- A. Administer medications to increase stroke volume.
- B. Provide analgesics.
- C. Obtain a STAT electrocardiogram and troponins.
- D. Administer fluid replacement to increase blood pressure.
Correct Answer: D
Rationale: These findings suggest cardiogenic shock with pulmonary edema. Fluid replacement may be needed, but cautiously, to optimize preload.
The nurse observes the following tracing on the telemetry monitor. The nurse should take which initial action? See the image below.
- A. Assess the client's level of consciousness
- B. Prepare the client for immediate defibrillation
- C. Administer a dose of intravenous epinephrine
- D. Evaluate the client's cardiac lead placement
Correct Answer: B
Rationale: A life-threatening rhythm like ventricular fibrillation requires immediate defibrillation to restore normal rhythm.
Which of the following interventions should the nurse implement to manage fluid volume overload in a client with heart failure? Select all that apply.
- A. Administer diuretics as prescribed
- B. Monitor daily weights
- C. Restrict fluid intake to 500 mL per day
- D. Assess lung sounds for crackles
- E. Encourage high-sodium diet
- F. Assess lung sounds for rhonchi
Correct Answer: A,B,D
Rationale: Diuretics reduce fluid overload. Daily weights monitor fluid status. C: Incorrect - 500 mL/day is too restrictive; 1.5-2 L is typical. D: Correct - Crackles indicate pulmonary edema. E: Incorrect - High-sodium diets worsen fluid retention. F: Incorrect - Rhonchi are not specific to fluid overload.
Which of the following heart sounds would the nurse expect to auscultate in a client with systolic heart failure? Select all that apply.
- A. S1
- B. S2
- C. S3
- D. S4
- E. Pleural friction rub
Correct Answer: C
Rationale: S1 is a normal heart sound. B: Incorrect - S2 is a normal heart sound. C: Correct - S3 is associated with systolic heart failure due to rapid ventricular filling. D: Incorrect - S4 is linked to diastolic dysfunction, not systolic failure. E: Incorrect - Pleural friction rub indicates pleural inflammation, not heart failure.
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.
For each medication, choose the most likely option for drug classification and mechanism of action for heart failure: Spironolactone, Sacubitril/Valsartan, Dapagliflozin
- A. Spironolactone: MRA, Blocks aldosterone effects
- B. Sacubitril/Valsartan: ARNI, Blocks RAAS and neprilysin
- C. Dapagliflozin: SGLT2 inhibitor, Causes osmotic diuresis
Correct Answer: A,B,C
Rationale: Spironolactone: MRA (Mineralocorticoid Receptor Antagonist) blocks aldosterone, reducing fluid retention. Sacubitril/Valsartan: ARNI blocks RAAS and neprilysin, improving vasodilation and diuresis. Dapagliflozin: SGLT2 inhibitor causes osmotic diuresis, reducing fluid overload.