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

Explanation

A. Pruritus is not a common side effect of heparin therapy. While allergic reactions can occur, they are not the primary concern.
B. Petechiae are a sign of bleeding, which is a major side effect of heparin therapy. Heparin increases the risk of bleeding by inhibiting clot formation, and petechiae may indicate early signs of hemorrhage.
C. Confusion is not directly associated with heparin therapy unless it results from severe bleeding leading to hypoxia or shock.
D. A slowing pulse rate is not a known adverse effect of heparin. Instead, monitoring for signs of bleeding, such as bruising, hematuria, and petechiae, is the priority.

A. Count how many QRS complexes occur in a 6-second strip B. Measure the T waves C. Read the monitor or electrocardiogram interpretation D. Look for P waves on the strip

Correct Answer is A

Explanation

A. Counting the number of QRS complexes in a 6-second strip and multiplying by 10 provides an estimate of the heart rate per minute.
B. Measuring T waves is used to assess repolarization abnormalities, not to determine heart rate.
C. While the monitor provides a heart rate reading, manual calculation is essential for verifying accuracy.
D. P waves indicate atrial activity but are not used to calculate the overall heart rate.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving intravenous heparin therapy for deep vein thrombosis. The nurse evaluates for side effects of this drug by observing for:

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about evaluating cardiac rhythms. Which of the following best explains calculation of the heart rate?

Correct Answer is A

Explanation

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Identify the following Cardiac Rhythm:

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