Nokea
Which of the following interventions should the nurse implement to manage fluid volume overload in a client with heart failure? Select all that apply.
- A. Administer diuretics as prescribed
- B. Monitor daily weights
- C. Restrict fluid intake to 500 mL per day
- D. Assess lung sounds for crackles
- E. Encourage high-sodium diet
- F. Assess lung sounds for rhonchi
Correct Answer: A,B,D
Rationale: Diuretics reduce fluid overload. Daily weights monitor fluid status. C: Incorrect - 500 mL/day is too restrictive; 1.5-2 L is typical. D: Correct - Crackles indicate pulmonary edema. E: Incorrect - High-sodium diets worsen fluid retention. F: Incorrect - Rhonchi are not specific to fluid overload.
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The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure?
- A. ascites
- B. tachypnea
- C. cough
- D. orthopnea
Correct Answer: A
Rationale: Right-sided heart failure causes systemic congestion, leading to ascites due to fluid accumulation in the abdomen.
The nurse is caring for a client who is reporting pain in their left lower leg. How should the nurse assess for the presence of thrombophlebitis?
- A. By palpating the skin over the tibia and fibula
- B. By documenting daily calf circumference measurements
- C. By recording vital signs obtained four times a day
- D. By noting difficulty with ambulation
Correct Answer: B
Rationale: Measuring calf circumference detects swelling, a key sign of thrombophlebitis, indicating possible deep vein thrombosis.
The nurse in the emergency department (ED) is assessing a client who may have an acute myocardial infarction. Which of the following findings would support this diagnosis?
- A. U-waves
- B. T-wave inversion
- C. ST-segment elevation
- D. Prolonged PR-interval
Correct Answer: C
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
Which of the following statements correctly outlines the proper flow of blood through the heart?
- A. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation
- B. Superior and Inferior vena cavas → Right atrium → Mitral valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Tricuspid valve → Left ventricle → Aortic valve → Aorta → Systemic circulation
- C. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary veins → Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation
- D. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Aortic valve → Pulmonary veins → Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Pulmonary valve → Aorta → Systemic circulation
Correct Answer: A
Rationale: This sequence accurately describes blood flow: deoxygenated blood enters the right heart, is pumped to the lungs, and oxygenated blood returns to the left heart for systemic circulation.
The nurse is caring for a client diagnosed with acute pericarditis. Which complication is the client at risk for developing?
- A. cardiac tamponade
- B. hemothorax
- C. pulmonary embolism
- D. tension pneumothorax
Correct Answer: A
Rationale: Acute pericarditis can lead to pericardial effusion, which may progress to cardiac tamponade, compressing the heart.