A client admitted with heart failure is able to initiate brushing their teeth and combing their hair but unable to finish these activities or wash their body due to dyspnea and fatigue. Upon ambulation to the bathroom, the patient also experiences dyspnea, fatigue, and chest pain. Based upon this information, what New York Heart Association Classification will be assigned to this client?

III

Answer and Explanation

The Correct Answer is D

A. Class I: No limitation of physical activity; ordinary activity does not cause symptoms. This client clearly experiences symptoms with ordinary activities.
B. Class II: Slight limitation of physical activity; comfortable at rest, but ordinary activity causes fatigue, dyspnea, or chest pain. This client is more limited than Class II.
C. Class IV: Unable to carry out any physical activity without discomfort; symptoms may be present even at rest. This client does not have symptoms at rest.
D. Class III: Marked limitation of physical activity; comfortable at rest, but less-than-ordinary activity (e.g., brushing teeth, walking to the bathroom) causes fatigue, dyspnea, or chest pain. This best fits the client's condition.

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Correct Answer is B

Explanation

A. Blood flowing back from the left atrium to the left ventricle describes mitral regurgitation, not aortic regurgitation.
B. Aortic regurgitation involves the backflow of blood from the aorta into the left ventricle during diastole due to an incompetent aortic valve. This leads to volume overload in the left ventricle.
C. Obstruction of blood from the left atrium to the left ventricle occurs in mitral stenosis, not aortic regurgitation.
D. Obstruction of blood flow from the left ventricle is characteristic of aortic stenosis, not aortic regurgitation.

A. Monitor blood pressure. B. Assess radial pulses. C. Monitor bowel movements. D. Monitor weight daily.

Correct Answer is D

Explanation

A. Monitor blood pressure – While important, blood pressure changes are not the most sensitive or early indicator of fluid retention in heart failure.
B. Assess radial pulses – Pulse assessment can reflect cardiac output, but it does not directly indicate fluid balance.
C. Monitor bowel movements – Bowel function is not typically affected by fluid balance in heart failure and is not a relevant measure.
D. Monitor weight daily – Daily weight monitoring is the most accurate and early indicator of fluid retention in clients with heart failure. A weight gain of 2–3 pounds in a day or 5 pounds in a week may indicate fluid overload and should be reported to the healthcare provider.

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Naxlex Comprehensive Predictor Exams

A client with aortic regurgitation is being transferred from the critical care unit to the step-down unit. The nurse receiving the patient in the step-down unit is aware that aortic regurgitation causes:

Correct Answer is B

Explanation

When being discharged home, to assess fluid balance, a client with heart failure should be instructed to:

Correct Answer is D

Explanation

When auscultating the breath sounds of a client with pericarditis, the nurse would expect to find which of the following?

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

During the refractory stage of shock in hypovolemia, which of the following responses accurately describes the physiological changes that occur?

A 57-year-old-client is being admitted to the intensive care unit (ICU) with a diagnosis of possible septic shock He has a normal blood pressure, increased heart rate, decreased bowel sounds, and their skin is cold and clammy. The ICU nurse suspects the client:

What is the nurse's priority when caring for a patient in septic shock?

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

The nurse is teaching a beginning ECG class to staff nurses. As the nurse begins to discuss the parts of the ECG complex, one of the students asks what the normal order of conduction through the heart is. The correct response would be which of the following?