The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

"How many pillows do you sleep on mister"

"Do you have chest pain when you walk up the steps?"

"Do you find that your rings and shoes feel tight at the end of the day?"

"How many times do you get up to void at night?"

Answer and Explanation

The Correct Answer is A

A.   This question assesses the client's level of orthopnea, which is a condition where the client experiences difficulty breathing when lying flat. People with heart failure may need to use multiple pillows to prop themselves up to breathe more easily at night, making it an important question to assess respiratory status.
B.   Chest pain with exertion can be indicative of cardiovascular issues but this question does not directly assess the client's respiratory status.
C.   Tight rings and shoes can indicate fluid retention and edema, but it does not provide specific information about respiratory status.
D.   Frequent nighttime voiding (nocturia) is common in heart failure, but it relates more to kidney function and fluid retention rather than respiratory function.

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Correct Answer is C

Explanation

A. Counting the number of large squares between R-R intervals and dividing by 30 is not the correct method for estimating the ventricular rate on an ECG strip.
B. Printing a 1-minute ECG strip and counting the QRS complexes (option B) is accurate but unnecessary for a quick estimation.
C. The most common and efficient method for estimating the ventricular rate quickly is to count the number of QRS complexes in a 6-second strip (often marked by two dashed lines) and multiply by 10. This gives an estimate of the heart rate per minute.
D. Counting the number of small squares between QRS complexes and dividing by 1500 is the most accurate method but requires more time and precision than counting QRS complexes in 6 seconds.

A. diltiazem. B. nitroglycerine. C. verapamil. D. morphine.

Correct Answer is D

Explanation

A. Diltiazem is a calcium channel blocker that can be used to manage conditions like atrial fibrillation or hypertension by slowing the heart rate and reducing blood pressure. However, it may not be the most appropriate drug in the acute setting for heart failure with dyspnea.
B. Nitroglycerine is a vasodilator that helps reduce preload and afterload, which can be beneficial in heart failure. However, it primarily works by reducing the workload on the heart and may help with fluid overload but may not directly address anxiety.
C. Verapamil is another calcium channel blocker that slows the heart rate and reduces the heart's workload. While it may be useful for controlling tachyarrhythmias, it is not the best option for managing acute heart failure with severe dyspnea and anxiety.
D. Morphine is an opioid that can be used in acute heart failure to reduce both anxiety and respiratory distress. It works by reducing the sympathetic nervous system response, decreasing heart rate and blood pressure, and providing a sense of calm, which reduces anxiety. It also reduces preload by venodilation and helps manage severe dyspnea.

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The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

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Naxlex Comprehensive Predictor Exams

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