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: Effectively managing pain, discomfort, and diarrhea is important for the client’s quality of life, but it does not address the long-term goal of preventing disease progression and complications.

Choice B reason: Ensuring careful fluid and electrolyte balance is critical, especially during acute exacerbations, but it is more of an immediate concern rather than a long-term goal.

Choice C reason: Reducing the number and severity of acute exacerbations is the most important long-term goal for clients with chronic ulcerative colitis. This goal focuses on maintaining remission, preventing complications, and improving overall prognosis by minimizing flare-ups.

Choice D reason: Maintaining a diet that is high in fibber content can be beneficial for overall health but may not always be suitable for clients with ulcerative colitis, especially during flare-ups. It is not the most critical long-term goal for managing the condition.

A. Bounding peripheral pulse. B. uneven hair distribution. C. Lower leg enema. D. bronze pigmentation.

Correct Answer is B

Explanation

Choice A reason: A bounding peripheral pulse indicates increased arterial circulation and is not a sign of compromised peripheral arterial circulation. In cases of arterial insufficiency, pulses may actually be diminished or absent.

Choice B reason: Uneven hair distribution is a classic sign of compromised peripheral arterial circulation. Poor blood flow to the extremities can lead to decreased hair growth, causing patchy or uneven hair distribution. This symptom is often seen in clients with peripheral arterial disease.

Choice C reason: Lower leg enema is more commonly associated with venous insufficiency rather than arterial insufficiency. Edem results from fluid accumulation due to poor venous return rather than issues with arterial circulation.

Choice D reason: Bronze pigmentation is often related to chronic venous insufficiency and hemosiderin deposition in the skin. It is not typically a sign of compromised arterial circulation. Arterial issues are more likely to cause pallor or cyanosis in the affected extremity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

Correct Answer is C

Explanation

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

Correct Answer is B

Explanation

The practical nurse (PN) reports to the charge nurse that a client who is receiving a parenteral nutrition infusion has a capillary glucose of 365 mg/dL (20.3 mmol/L). Which action should the charge nurse implement?

A client with hyperthyroidism tells the home health nurse, "I stopped taking my antithyroid medication and now I feel anxious. I can feel my heart racing and pounding." Which assessment is most important for the nurse to obtain?

A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?

A 26-year-old client is admitted to the hospital for treatment of a simple goitre, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

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The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behaviour indicates that the client is adhering to the eating plan?