Nokea
What is the priority problem in the client diagnosed with congestive heart failure?
- A. Fluid volume overload.
- B. Decreased cardiac output.
- C. Activity intolerance.
- D. Knowledge deficit.
Correct Answer: B
Rationale: Decreased cardiac output (B) is the primary problem in CHF, causing symptoms like fluid overload (A). Activity intolerance (C) and knowledge deficit (D) are secondary.
You may also like to solve these questions
Which client problem has priority for the client with a cardiac dysrhythmia?
- A. Alteration in comfort.
- B. Decreased cardiac output.
- C. Impaired gas exchange.
- D. Activity intolerance.
Correct Answer: B
Rationale: Dysrhythmias primarily reduce cardiac output (B), impacting perfusion, making it the priority. Comfort (A), gas exchange (C), and activity (D) are secondary.
The nurse is told in report the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal notch.
- B. Erb's point.
- C. Second intercostal space, left sternal notch.
- D. Fourth intercostal space, left sternal border.
Correct Answer: A
Rationale: Aortic stenosis murmur is best heard at the second intercostal space, right sternal notch (A), where the aortic root is closest. Erb’s point (B), left sternal notch (C), and fourth space (D) are for other murmurs.
The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching?
- A. The client takes prophylactic antibiotics.
- B. The client uses a soft-bristle toothbrush.
- C. The client takes an enteric-coated aspirin daily.
- D. The client alternates rest with activity.
Correct Answer: C
Rationale: Aspirin (C) is not routinely required post-mechanical valve; warfarin is standard. Antibiotics (A), soft toothbrush (B), and rest/activity (D) are appropriate.
The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client?
- A. Instruct the client to use a soft-bristle toothbrush.
- B. Discuss the importance of getting a monthly partial thromboplastin time (PTT).
- C. Teach the client about signs of pacemaker malfunction.
- D. Explain to the client the procedure for synchronized cardioversion.
Correct Answer: A
Rationale: Atrial fibrillation requires anticoagulation, increasing bleeding risk; a soft-bristle toothbrush (A) prevents gum bleeding. PTT (B) monitors heparin, not warfarin, pacemakers (C) are unrelated, and cardioversion (D) is not routine.
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse?
- A. The client's BP is 110/70 and pulse is 90.
- B. The client's groin dressing is dry and intact.
- C. The client refuses to keep the leg straight.
- D. The client denies any numbness and tingling.
Correct Answer: C
Rationale: Refusing to keep the leg straight (C) risks bleeding from the femoral site, requiring immediate intervention. Normal BP/pulse (A), intact dressing (B), and no numbness (D) are expected.