Nokea
The nursing team develops a care plan and expected outcomes for the client's recovery. Which expected outcomes are most important? Select all that apply.
- A. The client will not gain weight.
- B. The client will not gain weight.
- C. The client will comply with the dietary restrictions.
- D. The client will avoid any alcoholic beverages.
- E. The client will verbalize fears and anxieties freely.
- F. The client will maintain pressure over the intravenous site.
Correct Answer: C,D,E
Rationale: Complying with dietary restrictions, avoiding alcohol, and verbalizing fears support recovery by reducing cardiac risk and addressing emotional needs.
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Because the client is exhibiting signs and symptoms of congestive heart failure (CHF), which position suggested by the nurse is most beneficial for the client at this time?
- A. Supine with knees slightly bent
- B. Side-lying on the right side
- C. Side-lying on the left side
- D. Semi-Fowler's position
Correct Answer: D
Rationale: Semi-Fowler's position (30-45 degrees) reduces preload and eases breathing in CHF.
Which symptom would the nurse expect to observe if the client is having an allergic reaction to streptokinase (Streptase)?
- A. Urticaria
- B. Anuria
- C. Hemoptysis
- D. Dyspepsia
Correct Answer: A
Rationale: Urticaria (hives) is a common sign of an allergic reaction to streptokinase, a thrombolytic agent.
When the nurse informs the client about the use of the PCA pump, which instruction is most important to include?
- A. Press the button only when pain is severe.
- B. Only the client should press the PCA button.
- C. Wait 30 minutes between doses.
- D. Record the number of doses used.
Correct Answer: B
Rationale: Only the client should press the PCA button to prevent overdose and ensure pain relief is patient-controlled.
If the client's severe chest pain is typical of other people who experience myocardial infarction (MI), the client is most likely to tell the nurse that the discomfort radiates to which area?
- A. Flank
- B. Groin
- C. Abdomen
- D. Shoulder
Correct Answer: D
Rationale: MI pain typically radiates to the shoulder, arm, or jaw due to referred pain from cardiac ischemia.
The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include?
- A. Instruct the client to take a cough suppressant if a cough develops.
- B. Teach the client how to prevent orthostatic hypotension.
- C. Encourage the client to eat bananas to increase potassium level.
- D. Explain the importance of taking the medication with food.
Correct Answer: B
Rationale: ACE inhibitors cause hypotension, so teaching prevention of orthostatic hypotension (B) is critical. Cough suppressants (A) are inappropriate for ACE inhibitor cough, bananas (C) are unnecessary unless hypokalemia exists, and food (D) is not required.