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The telemetry nurse notes a peaked T wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess?
- A. CK-MB.
- B. Troponin.
- C. BNP.
- D. Potassium.
Correct Answer: D
Rationale: Peaked T waves indicate hyperkalemia; assessing potassium (D) is critical in CHF patients on diuretics. CK-MB (A) and troponin (B) are for MI, BNP (C) for heart failure severity.
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The telemetry nurse is unable to read the telemetry monitor at the nurse’s station. Which intervention should the telemetry nurse implement first?
- A. Go to the client's room to check the client.
- B. Instruct the primary nurse to assess the client.
- C. Contact the client on the client call system.
- D. Request the nursing assistant to take the crash cart to the client's room.
Correct Answer: A
Rationale: An unreadable monitor (A) requires direct client assessment to ensure safety. Instructing another nurse (B), calling (C), or crash cart (D) are premature without assessment.
The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client?
- A. Apical pulse rate of 110 and 4+ pitting edema of feet.
- B. Thick white sputum and crackles that clear with cough.
- C. The client sleeping with no pillow and eupnea.
- D. Radial pulse rate of 90 and CRT less than three (3) seconds.
Correct Answer: A
Rationale: CHF exacerbation causes fluid overload, leading to tachycardia (apical pulse 110) and severe edema (4+ pitting, A). Thick sputum/crackles (B) suggest pneumonia, sleeping flat with eupnea (C) is unlikely, and normal CRT (D) doesn’t reflect CHF severity.
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 intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy?
- A. Keep the client in the supine position with the legs elevated.
- B. Discuss a heart transplant, which is the definitive treatment.
- C. Prepare the client for coronary artery bypass graft.
- D. Teach the client to take a calcium channel blocker in the morning.
Correct Answer: B
Rationale: Dilated cardiomyopathy may require heart transplant (B) as definitive treatment in severe cases. Supine position (A) increases preload, CABG (C) is for CAD, and calcium channel blockers (D) are not first-line.
Which prothrombin time value would be considered normal for a client who is receiving warfarin (Coumadin)?
- A. 12 seconds
- B. 20 seconds
- C. 60 seconds
- D. 98 seconds
Correct Answer: B
Rationale: For a client receiving warfarin, the prothrombin time should be 1.5 to 2 times the normal value (11 to 12.5 seconds). Twenty seconds falls within this therapeutic range. Twelve seconds is normal for someone not on warfarin. Sixty seconds is normal for a partial thromboplastin time (PTT) test, and 98 seconds would be therapeutic for heparin, not warfarin.