A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Tachycardia

Weight gain

Decreased thirst

Thready pulse

Answer and Explanation

The Correct Answer is B

A.   While tachycardia can occur in some cases of heart failure as a compensatory mechanism, it's not a universal manifestation.
B.   In heart failure, weight gain is a common manifestation due to fluid retention caused by the heart's inability to pump blood effectively. This fluid buildup can lead to an increase in body weight, often evidenced by swelling in the legs, ankles, or abdomen.
C.   Heart failure often leads to increased thirst due to fluid overload and decreased cardiac output, resulting in poor tissue perfusion.
D.   A thready pulse may be present in heart failure due to decreased stroke volume, but it's not a primary manifestation typically associated with the condition.

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Correct Answer is B,C,A,D

Explanation

The nurse should first review the skill level and qualifications of each AP then communicate appropriate tasks to the APs with specific expectations, then monitor progress of task completion with each AP; and lastly evaluate the APs' performance of each task. This sequence ensures that tasks are delegated appropriately and that the APs' performance is monitored and evaluated.

A. Monitor the child's cardiac status. B. Give scheduled doses of acetaminophen every 6 hr. C. Provide stimulation with children of the same age in the play room. D. Administer antibiotics via intermittent IV bolus for 24 hr.

Correct Answer is A

Explanation

A. Kawasaki disease involves inflammation of the blood vessels and can lead to serious cardiac complications, including coronary artery aneurysms. Monitoring cardiac status is essential to detect and manage these risks.
B. While managing fever is a part of treating Kawasaki disease, acetaminophen is typically used as needed rather than on a strict schedule unless fever is persistent.
C. During the acute phase of Kawasaki disease, children often feel very irritable and unwell; large group activities may be overwhelming and inappropriate.
D. Kawasaki disease is not caused by a bacterial infection, and antibiotics are not part of the treatment. Instead, treatment usually involves high-dose aspirin and intravenous immunoglobulin.

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Body Systems	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Hard stool
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Red/orange tint to urine Darkening of the urine

A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. (Move the steps, placing them in the selected order of performance. Use all the steps.)

Correct Answer is B,C,A,D

Explanation

A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

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