Nokea
Which assessment finding indicates a worsening condition in a client with valvular heart disease? Select all that apply.
- A. Shortness of breath at rest
- B. Weight gain of 4 pounds in 3 days
- C. Fatigue with minimal activity
- D. Blood pressure of 130/80 mmHg
- E. Bilateral crackles in lungs
- F. Heart rate of 80 beats per minute
Correct Answer: A,B,C,E
Rationale: Shortness of breath, weight gain, fatigue, and crackles indicate worsening heart failure due to valvular dysfunction.
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The nurse is caring for clients on a medical floor. Which client will the nurse assess first?
- A. The client with an abdominal aortic aneurysm who is constipated.
- B. The client on bedrest who ambulated to the bathroom.
- C. The client with essential hypertension who has epistaxis and a headache.
- D. The client with arterial occlusive disease who has a decreased pedal pulse.
Correct Answer: D
Rationale: Decreased pedal pulse in arterial occlusive disease (D) suggests acute ischemia, a priority. Constipation (A), unauthorized ambulation (B), and epistaxis/headache (C) are less urgent.
The client with a left-sided mastectomy is diagnosed with elephantiasis of the left arm. Which signs/symptoms should the nurse expect to assess?
- A. Edematous arm from the axillary area to the fingertips.
- B. Painful, edematous, reddened lower forearm.
- C. Tented skin turgor over the entire left arm.
- D. Nipple retraction and peau d’orange skin.
Correct Answer: A
Rationale: Elephantiasis causes chronic lymphedema, leading to arm edema from axilla to fingertips (A). Pain/redness (B) suggests infection, tented turgor (C) is dehydration, and nipple changes (D) are breast cancer signs.
The client with heart failure is prescribed digoxin. Which finding should the nurse report immediately?
- A. Heart rate of 58 beats per minute
- B. Potassium level of 3.2 mEq/L
- C. Blood pressure of 130/85 mmHg
- D. Respiratory rate of 18 breaths per minute
Correct Answer: B
Rationale: Hypokalemia (low potassium) increases the risk of digoxin toxicity, requiring immediate reporting.
Which instruction should the nurse provide to a client with endocarditis?
- A. Take antibiotics exactly as prescribed.
- B. Increase dietary sodium intake.
- C. Avoid dental checkups.
- D. Resume heavy lifting in 2 weeks.
Correct Answer: A
Rationale: Adhering to antibiotic therapy is critical to eradicate the infection in endocarditis.
Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease?
- A. Encourage the client to use a heating pad on the lower extremities.
- B. Demonstrate to the client the correct way to apply elastic support hose.
- C. Instruct the client to walk daily for at least 30 minutes.
- D. Tell the client to check both feet for red areas at least once a week.
Correct Answer: C
Rationale: Daily walking for 30 minutes (C) promotes collateral circulation in PAD. Heating pads (A) risk burns, elastic hose (B) are for venous disease, and weekly checks (D) are insufficient (daily needed).