Nokea
To provide adequate care for the client with worsening left-sided heart failure, the intensive care unit (ICU) nurse should be a full of the following on a daily basis?
- A. Pupil response
- B. Peripheral edema
- C. Appetite
- D. Weight
Correct Answer: B,D
Rationale: Peripheral edema and weight are key indicators of fluid status in heart failure.
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During the admission interview, a client who is admitted for a cardiac catheterization says, 'Every time I eat shrimp I get a rash.' What action is essential for the nurse to take at this time?
- A. Notify the physician.
- B. Ask the client if she gets a rash from any other foods.
- C. Instruct the dietary department not to give the client shrimp.
- D. Teach the client the dangers of eating shrimp and other shellfish.
Correct Answer: A
Rationale: A shrimp allergy may indicate an iodine allergy, as shellfish contain iodine, which is also present in the dye used for cardiac catheterization. Notifying the physician is essential to assess the risk and consider alternative dyes or premedication. Asking about other foods, instructing the dietary department, or teaching about shellfish dangers are secondary actions.
What should be included in foot care for the client who has a peripheral vascular disorder?
- A. Soaking the feet for 20 minutes before washing them
- B. Walking barefoot only on carpeted floors
- C. Applying lotion between the toes to avoid cracking of the skin
- D. Avoiding exposure of the legs and feet to the sun
Correct Answer: D
Rationale: Avoiding sun exposure prevents skin damage in clients with compromised circulation due to peripheral vascular disease. Soaking, walking barefoot, or applying lotion between toes increase infection or injury risk.
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.
The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?
- A. Call a code immediately.
- B. Assess the client for a pulse.
- C. Begin chest compressions.
- D. Continue to monitor the client.
Correct Answer: B
Rationale: Ventricular tachycardia requires assessing for a pulse (B) to determine if it’s pulseless (needing CPR, C) or stable (medication). Calling a code (A) or monitoring (D) depends on pulse status.
The best evidence that the client is complying with the diet therapy is the report of using which type of fat for cooking?
- A. Melted margarine
- B. Clarified butter
- C. Cooking spray
- D. Liquid corn oil
Correct Answer: C
Rationale: Cooking spray is low in saturated fat and calories, aligning with a heart-healthy diet to control CAD progression.