A nurse is caring for a client with congestive heart failure (CHF). Which of the following symptoms would indicate worsening of the condition?

The client reports increased shortness of breath.

The client has a temperature of 37°C (98.6°F).

The client has a blood pressure of 120/80 mmHg.

The client reports occasional dizziness.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Increased shortness of breath is a key symptom of worsening congestive heart failure (CHF). It indicates that the heart is not effectively pumping blood, leading to fluid buildup in the lungs and increased respiratory effort.
Choice B rationale
A temperature of 37°C (98.6°F) is within the normal range and does not indicate worsening CHF. Monitoring the patient’s temperature is important, but it is not a sign of CHF exacerbation.
Choice C rationale
A blood pressure of 120/80 mmHg is within the normal range and does not indicate worsening CHF. Blood pressure should be monitored, but this reading does not suggest an acute issue.
Choice D rationale
Occasional dizziness can be a symptom of many conditions, including CHF, but it is not as specific or critical as increased shortness of breath. It should be monitored, but it does not indicate an immediate worsening of CHF.

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Correct Answer is C

Explanation

Choice A rationale
Hyperkalemia can cause weakness and fatigue, but it is not directly related to acute coronary syndrome (ACS). ACS is primarily associated with chest pain and other cardiac symptoms.
Choice B rationale
Experiencing chest pain when climbing a flight of stairs may indicate stable angina, which is a form of chronic coronary artery disease. However, it does not meet the criteria for ACS, which involves more severe and persistent symptoms.
Choice C rationale
Persistent and severe chest pain when at rest is a hallmark symptom of acute coronary syndrome (ACS). This condition requires immediate medical attention as it can lead to myocardial infarction (heart attack) or other serious complications.
Choice D rationale
Paroxysmal nocturnal dyspnea (PND) is a symptom of heart failure, not acute coronary syndrome (ACS). While heart failure can coexist with ACS, PND alone does not indicate ACS4.

A. Maintain the client in a supine position. B. Maintain a high-Fowler’s position when the client is in bed. C. Elevate the stump on a pillow. D. Position the client on the abdomen for 20 to 30 minutes twice a day.

Correct Answer is D

Explanation

Choice D rationale

Positioning the client on the abdomen for 20 to 30 minutes twice a day helps prevent hip flexion contractures. This position stretches the hip flexor muscles, reducing the risk of contractures and promoting better range of motion.

Choice A rationale

Maintaining the client in a supine position does not effectively prevent hip flexion contractures. It is important to vary the client’s position to avoid stiffness and promote mobility.

Choice B rationale

Maintaining a high-Fowler’s position when the client is in bed can increase the risk of hip flexion contractures. This position keeps the hip flexed, which can lead to contractures over time.

Choice C rationale

Elevating the stump on a pillow can help reduce swelling but does not address the prevention of hip flexion contractures. The focus should be on positioning that stretches the hip flexors.

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A nurse is caring for a client with congestive heart failure (CHF). Which of the following symptoms would indicate worsening of the condition?

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Naxlex Comprehensive Predictor Exams

Which individual is suffering from the effects of acute coronary syndrome (ACS)?

Correct Answer is C

Explanation

The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?

Correct Answer is D

Explanation

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