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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.
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The nurse has written an outcome goal 'demonstrates tolerance for increased activity' for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?
- A. Measure intake and output.
- B. Provide two (2)g sodium diet.
- C. Weigh the client daily.
- D. Plan for frequent rest periods.
Correct Answer: D
Rationale: Frequent rest periods (D) prevent overexertion, supporting activity tolerance in CHF. Intake/output (A), sodium diet (B), and daily weights (C) are important but less directly related to activity.
The client with infective endocarditis is admitted to the medical department. Which health-care provider’s order should be implemented first?
- A. Administer intravenous antibiotic.
- B. Obtain blood cultures times two (2).
- C. Schedule an echocardiogram.
- D. Encourage bedrest with bathroom privileges.
Correct Answer: B
Rationale: Blood cultures (B) are obtained first in endocarditis to identify the pathogen before antibiotics (A) obscure results. Echocardiogram (C) and bedrest (D) follow.
The nurse identifies the concept of altered tissue perfusion related to a client admitted with atrial fibrillation. Which interventions should the nurse implement? Select all that apply.
- A. Monitor the client's blood pressure and apical rate every four (4) hours.
- B. Place the client on intake and output every shift.
- C. Require the client to sleep with the head of the bed elevated.
- D. Teach the patient to perform Buerger Allen exercises daily.
- E. Determine if the client is on an antiplatelet or anticoagulant medication.
- F. Assess the client's neurological status every shift and prn.
Correct Answer: A,E,F
Rationale: Monitoring BP/apical rate (A), anticoagulation status (E), and neurological status (F) address AF-related perfusion risks (clots, stroke). I/O (B) is for fluid status, HOB elevation (C) is for CHF, and Buerger Allen (D) is for PAD.
The nurse is administering morning medications. Which medication should be administered first?
- A. The cardiac glycoside medication, digoxin, to a client diagnosed with heart failure and who has 2+ edema of the feet.
- B. The sliding scale insulin to a client with a fasting blood glucose of 345 mg/dL who is demanding breakfast.
- C. The loop diuretic, furosemide, to a client with a 24-hour intake of 986 mL and an output of 1,400 mL.
- D. The ARB medication to a client whose blood pressure was reported by the unlicensed assistive personnel as 142/76.
Correct Answer: B
Rationale: Fasting glucose of 345 mg/dL (B) requires immediate insulin to prevent complications, especially before eating. Digoxin (A), furosemide (C), and ARB (D) are less urgent.
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.