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 ["A","D","G"]

Explanation

A. Allowing the client to find a comfortable position can help reduce anxiety and promote relaxation, which can be beneficial during an asthma exacerbation.
B. While the patient is currently receiving treatment with albuterol and oxygen, discussing aggressive respiratory treatment options may not be necessary at this moment unless the patient's condition deteriorates and requires escalation of care.
C. Deep tracheal suctioning is not indicated based on the current assessment findings unless there is a specific clinical indication such as excessive secretions or respiratory distress.
D. Identifying and discussing potential triggers is important for asthma management. This helps the client understand what factors might exacerbate their asthma and how to avoid them in the future.
E. Since the patient's oxygen saturation is still below target (91% on room air), weaning the supplemental oxygen is not appropriate at this time. The oxygen therapy should be continued as per the titration orders to maintain saturation above 94%.
F. Obtaining a sputum culture is not typically indicated in acute asthma exacerbations unless there is suspicion of a secondary infection or if the patient develops persistent fever and productive cough.
G. Continuously monitoring oxygen saturation is crucial to ensure it remains above 94%. This helps gauge the effectiveness of treatment and ensures the patient's respiratory status is stable.
H. Positive pressure ventilation is a more advanced intervention and is not indicated based on the current assessment findings. It would only be considered if the patient's condition worsens despite maximal medical therapy.

A. Outreach for support group information. B. Domestic violence assistance. C. Blood pressure screening. D. Immunizations that are available.

Correct Answer is D

Explanation

Rationale

A. While support groups are important for individuals dealing with chronic illnesses or specific health issues, they are not directly related to primary disease prevention. Support groups focus more on coping, emotional support, and managing existing conditions rather than preventing diseases.

B. Domestic violence assistance is crucial for community health and safety, but it is not typically categorized under primary disease prevention. Domestic violence is a social issue that requires interventions aimed at prevention and support for victims, rather than preventing diseases through health promotion and education.

C. Blood pressure screening is an example of a primary disease prevention activity. High blood pressure (hypertension) is a significant risk factor for cardiovascular diseases such as heart attack and stroke. By screening individuals for hypertension, nurses can identify those at risk early and provide education on lifestyle modifications or medical interventions to prevent cardiovascular disease.

D. Immunizations are a cornerstone of primary disease prevention. Vaccines prevent infectious diseases by stimulating the immune system to produce immunity against specific pathogens. Community outreach programs that educate the public about immunizations help increase vaccination rates, thereby reducing the incidence of vaccine-preventable diseases in the population.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

Correct Answer is ["A","D","G"]

Explanation

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

Correct Answer is D

Explanation

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