Nokea
Using the following cardiac structures, trace the normal stress in which blood circulates on the left side of the heart. Use all the options.
- A. Aorta
- B. Left ventricle
- C. Pulmonary veins
- D. Left atrium
- E. Mitral valve (correct sequence: 3, 4, 5, 2, 1)
Correct Answer: D
Rationale: Blood flows: pulmonary veins → left atrium → mitral valve → left ventricle → aorta.
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The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?
- A. Do you have a daily bowel movement?'
- B. Do you get yearly chest x-rays (CXRs)?'
- C. Are you sexually active?'
- D. Have you had any weight change?'
Correct Answer: D
Rationale: Weight change (D) may indicate fluid retention or malnutrition, relevant to CAD management. Bowel movements (A), CXRs (B), and sexual activity (C) are less directly related.
When the client returns to the room after the percutaneous transluminal coronary angioplasty (PTCA) procedure, which assessment finding should be reported immediately to the physician?
- A. Urine output of 100 mL/hour
- B. Blood pressure of 108/68 mm Hg
- C. Dry mouth
- D. Chest pain
Correct Answer: D
Rationale: Chest pain post-PTCA may indicate re-occlusion or complications like stent thrombosis, requiring immediate reporting.
The licensed practical nurse (LPN) is assisting the registered nurse (RN) in developing the nursing care plan for an older adult who has congestive heart failure. Which nursing diagnosis is most likely to be included?
- A. Deficient fluid volume
- B. Impaired verbal communication
- C. Chronic pain
- D. Activity intolerance
Correct Answer: D
Rationale: Activity intolerance is common in congestive heart failure due to reduced cardiac output and fatigue. Fluid volume excess, not deficit, is typical, and communication or pain are less likely.
Which statement by the nurse is the best explanation for why the client needs to take the prescribed medication?
- A. It may destroy the virus causing your disease.
- B. It may reduce the scar tissue on the valve.
- C. It may stop blood clots from forming.
- D. It may prevent future bacterial infections.
Correct Answer: D
Rationale: Nafcillin is an antibiotic used to prevent bacterial endocarditis in valvular disease.
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.