A nurse is caring for a 74-year-old female client who reports experiencing increased shortness of breath.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Worsening of congestive heart failure is suggested by symptoms including labored breathing, coarse crackles, jugular vein distention (JVD), cool/clammy skin, and low oxygen saturation. These findings indicate pulmonary congestion due to fluid overload.
Applying O₂ at 6L/min helps improve oxygenation and alleviate respiratory distress. Lower-flow oxygen (such as 2L/min) may not be sufficient in acute heart failure exacerbation.
Monitoring respiratory rate is essential to track breathing effort and response to treatment.
Monitoring oxygen saturation helps assess oxygenation status and effectiveness of interventions.
Smoking cessation is important for long-term lung and cardiovascular health but does not address the acute issue.
WBC count and temperature are more relevant to infections like pneumonia rather than acute heart failure.

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Correct Answer is ["B","C","D"]

Explanation

A. A high-calcium diet does not contribute to DVT development. DVT risk factors are related to venous stasis, hypercoagulability, and endothelial damage.
B. Prolonged bed rest leads to venous stasis, increasing the risk of clot formation.
C. Post-operative clients are at higher risk for DVT due to immobility and surgical trauma, which can activate clotting mechanisms.
D. Oral contraceptive use increases the risk of DVT due to hormonal effects that promote clot formation.
E. A low BMI is not a risk factor for DVT. In contrast, obesity is a recognized risk factor due to increased venous pressure and inflammation.

A. Blood pressure reading of 110/70 and heart rate of 90 B. Swelling at the insertion site and cool extremity C. Oozing blood from the puncture site D. The client has not voided since returning to recovery

Correct Answer is B

Explanation

A. A blood pressure of 110/70 and heart rate of 90 is within normal limits and does not indicate an immediate complication.
B. Swelling at the insertion site and a cool extremity suggest arterial occlusion or hematoma formation, which is a serious complication requiring immediate intervention. This may indicate impaired blood flow to the limb.
C. Oozing blood from the site may require monitoring and pressure application but is not as concerning as signs of arterial compromise.
D. Not voiding post-procedure can be due to bedrest or IV contrast, but it is not an urgent concern.

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Naxlex Comprehensive Predictor Exams

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a client post-cardiac catheterization with a right femoral artery puncture site. The nurse is aware that which of the following findings needs to be reported to the interventional cardiologist as soon as it is identified?

Correct Answer is B

Explanation

A nurse is caring for a client with heart failure (HF) and preparing to give a daily dose of Digoxin (Lanoxin). The nurse understands the rationale for giving this medication for HF is which of the following?

Identify the following Cardiac Rhythm:

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

A nurse is caring for a client in a critical care unit who is 4 hours post-operative coronary artery bypass surgery. The nurse performs the reassessment and suspects the client may be developing a pericardial effusion. What assessment findings would the nurse note in this case?

A nurse is providing discharge instructions for a client diagnosed with congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

A nurse is reviewing the lab results and electrocardiogram (ECG) of a patient with End Stage Renal Disease (ESRD). The nurse correlates which ECG finding to a potassium level of 6.8?

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