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Which interventions would be appropriate for a client with decreased cardiac output? Select all that apply.
- A. Apply compression stockings
- B. Obtain a prescription for nitroglycerin via transdermal patch
- C. Elevate the client's legs
- D. Implement fall precautions
- E. Educate the client about not straining when defecating
Correct Answer: A,D,E
Rationale: Compression stockings improve venous return, supporting cardiac output. B: Incorrect - Nitroglycerin reduces preload, potentially worsening cardiac output in some cases. C: Incorrect - Leg elevation is not standard for low cardiac output and may worsen symptoms. D: Correct - Fall precautions are needed due to potential weakness or syncope. E: Correct - Avoiding straining prevents Valsalva maneuver, which can reduce cardiac output.
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The nurse reviews a client's lipid panel who is being treated for hyperlipidemia with simvastatin. Which of the following actions should the nurse take based on the results? See the results in the exhibit.
- A. Review the client's most recent creatinine
- B. Assess the client's adherence to the prescribed medication
- C. Determine if the client is adhering to a low salt diet
- D. Document the results as within normal limits
Correct Answer: B
Rationale: If lipid panel results are abnormal, assessing adherence to simvastatin is key, as non-compliance may explain ineffective treatment.
The nurse is watching the monitor of a client wearing a continuous cardiac monitor when it begins to alarm and fails to display any QRS complexes. Which nursing intervention should the nurse do first?
- A. Press record on the electrocardiogram
- B. Check the client's lead placement
- C. Call the code team
- D. Contact the health care provider
Correct Answer: B
Rationale: Absent QRS complexes may result from loose or disconnected leads, so checking lead placement is the first step.
The nurse has performed a cardiovascular assessment on a client, and while auscultating heart tones, the nurse auscultates a harsh blowing sound. The nurse should document this finding as a
- A. pericardial friction rub.
- B. heart murmur.
- C. normal lub-dub sounds.
- D. S3 heart sound.
Correct Answer: B
Rationale: A harsh blowing sound indicates a heart murmur, caused by turbulent blood flow, often due to valve dysfunction.
The nurse assesses the following telemetry strip for a client on a medical-surgical unit. Based on the rhythm, what is the priority action for the nurse to take? See the exhibit.
- A. Prepare for synchronized cardioversion
- B. Obtain a prescription for intravenous (IV) atropine
- C. Review the client's most recent labs
- D. Assess if the client has a carotid pulse (P)
Correct Answer: D
Rationale: A life-threatening rhythm (e.g., ventricular tachycardia) requires immediate assessment of pulse to determine if the client is stable or needs resuscitation.
The nurse is assessing a client with congestive heart failure. Which physical assessment finding should the nurse expect?
- A. Intermittent claudication
- B. S3 gallop
- C. Venous stasis ulcers
- D. Widened pulse pressure
Correct Answer: B
Rationale: An S3 gallop is a common finding in CHF, indicating fluid overload and ventricular dysfunction.