A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Volume of pedal pulses.

Length of capillary refill.

Rhythm of apical pulse.

Degree of skin elasticity.

Answer and Explanation

The Correct Answer is C

Rationale

A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.

B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.

C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.

D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.

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Correct Answer is D

Explanation

Rationale

A. Dill pickles and black olives are typically high in sodium due to the pickling process. High sodium intake can exacerbate hypertension by increasing fluid retention and raising blood pressure.

B. Canned chicken broth often contains a high amount of sodium unless it is specifically labeled as low sodium or reduced sodium. Barley itself is a nutritious whole grain, but the sodium content in canned broth might counterbalance its benefits.

C. Tomato juice can be a good choice for someone with hypertension as long as it is low in sodium or sodium-free. Tomatoes are rich in potassium and other nutrients beneficial for heart health. Gluten-free crackers can be a healthy addition if they are low in sodium and made from whole grains.

D. Sweet potatoes are a nutrient-dense food high in potassium, fiber, and various vitamins and minerals. They are naturally low in sodium and are considered heart-healthy due to their potassium content, which helps counteract the effects of sodium on blood pressure.

A. Drink electrolyte fluid replacements. B. Resume normal physical activity. C. Give a dose of regular insulin as prescribed. D. Measure urine output over the next 24 hours.

Correct Answer is C

Explanation

Rationale

A. This option may seem reasonable, as dehydration and electrolyte imbalances are concerns in DKA. However, simply drinking electrolyte fluids without addressing the underlying cause of DKA (which is insulin deficiency) would not effectively manage the condition.

B. Physical activity may exacerbate DKA if insulin levels are inadequate. It is important to stabilize blood glucose levels and manage DKA before engaging in physical activity.

C. In DKA, there is an absolute or relative deficiency of insulin, leading to hyperglycemia and ketosis. Regular insulin helps to lower blood glucose levels and inhibit further breakdown of fats into ketones, thereby correcting the metabolic imbalance associated with DKA.

D. Monitoring urine output is important in assessing hydration status, but it does not address the immediate need to manage DKA. This action alone would not correct the underlying cause of increased thirst in DKA.

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A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

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Naxlex Comprehensive Predictor Exams

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

Correct Answer is D

Explanation

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Correct Answer is C

Explanation

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