A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, "My heart feels like it is beating too fast and I feel faint." After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?

Degree of skin elasticity.

Length of capillary refill.

Rhythm of apical pulse.

Volume of pedal pulses.

Answer and Explanation

The Correct Answer is C

Choice A reason: The degree of skin elasticity is a measure often used to assess hydration status, especially in older adults. However, it does not provide direct information about the client's cardiac function or the cause of their current symptoms.

Choice B reason: The length of capillary refill is useful for assessing peripheral perfusion and overall circulatory status. While prolonged capillary refill can indicate poor perfusion, it does not provide specific information about heart rhythm or the cause of palpitations and faintness in a client with heart failure.

Choice C reason: The rhythm of the apical pulse is the most important assessment data to obtain in this scenario. The client's complaint of a fast-beating heart and feeling faint suggests a possible arrhythmia, which could be detected by assessing the rhythm of the apical pulse. This assessment can help identify irregular heartbeats, tachycardia, or other abnormalities that may require immediate intervention.

Choice D reason: The volume of pedal pulses can provide information about peripheral circulation, but it is not as crucial as assessing the heart rhythm in a client experiencing palpitations and faintness. Peripheral pulse volume may not change significantly with certain arrhythmias or cardiac issues that affect the central circulation more directly.

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Correct Answer is C

Explanation

Choice A reason: Obtaining a fingerstick glucose every 6 hours is important for monitoring blood glucose levels and ensuring they are within the target range. However, it is not the most critical intervention for preventing diabetic ketoacidosis. Testing for ketones provides more specific information on the development of DKA.

Choice B reason: Ensuring IV fluids are infusing continuously is crucial for maintaining hydration and preventing electrolyte imbalances, particularly in a client who may be at risk for DKA. However, this intervention is supportive and not as directly related to detecting the onset of DKA as testing for ketones.

Choice C reason: Testing urine for the presence of ketones is the most important intervention. The presence of ketones indicates that the body is breaking down fat for energy instead of using glucose, which is a hallmark of diabetic ketoacidosis. Early detection of ketones allows for prompt intervention to prevent the progression of DKA.

Choice D reason: Teaching the client how to manage sick days is essential for long-term diabetes management and preventing complications during illness. However, for the immediate prevention of DKA in the hospital setting, testing for ketones is more urgent and directly related to detecting and managing the condition.

A. Decrease dietary fat intake. B. Increase fluids and dietary fibber. C. Ingest frequent small meals. D. Reduce roughage in the diet.

Correct Answer is D

Explanation

Choice A reason: Decreasing dietary fat intake can be beneficial for overall health, but it is not specifically related to managing diverticulitis. Dietary fat does not directly influence the inflammation of diverticula.

Choice B reason: Increasing fluids and dietary fibber is important for preventing diverticulosis, which is the presence of diverticula in the colon. However, during an acute episode of diverticulitis, high fibber can exacerbate symptoms. Therefore, this recommendation is not appropriate during active inflammation.

Choice C reason: Ingesting frequent small meals can aid in digestion and prevent large meals from causing discomfort, but it does not directly address the dietary needs during diverticulitis.

Choice D reason: Reducing roughage in the diet is crucial during an acute episode of diverticulitis. High-fibber foods and roughage can irritate the inflamed diverticula and worsen symptoms. A low-fibber diet is often recommended until the inflammation subsides, after which a gradual return to a high-fibber diet can be beneficial to prevent future episodes.

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A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, "My heart feels like it is beating too fast and I feel faint." After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?

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Correct Answer is C

Explanation

Which diet modification should the nurse suggest to a client who was recently diagnosed with diverticulitis?

Correct Answer is D

Explanation

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