The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)
normal sinus rhythm that becomes sinus tachycardia
Onset of a cough with pink, frothy sputum
presence of dyspnea at rest
falls asleep when not disturbed
urine drainage is increased in amount
Correct Answer : A,B,C,D
A. Normal sinus rhythm that becomes sinus tachycardia
Sinus tachycardia can be an indication of increased sympathetic activity in response to decreased cardiac output. It may suggest the heart's compensatory response to maintain adequate perfusion.
B. Onset of a cough with pink, frothy sputum
Pink, frothy sputum is a classic sign of pulmonary edema, which can occur in the setting of worsening heart failure. It indicates the presence of blood-tinged fluid in the alveoli.
C. Presence of dyspnea at rest
Dyspnea at rest suggests that the client is experiencing difficulty breathing even without physical exertion. This can be indicative of more severe heart failure.
D. Falls asleep when not disturbed
Falling asleep when not disturbed may indicate fatigue or exhaustion, which is common in individuals with heart failure. However, it is not a direct indicator of worsening heart failure and can be influenced by various factors.
E. Urine drainage is increased in amount
Increased urine output can be a sign of diuretic therapy or an attempt by the body to compensate for fluid overload. However, it is essential to consider other factors such as renal function and medication effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Withhold food and oral fluids before the procedure
Withholding food and oral fluids before the procedure is essential to prevent complications during the cardiac catheterization. The client is typically NPO (nothing by mouth) for a specified period before the procedure.
B. Review medications the client has taken in the last 24 hours
Reviewing the client's medications is crucial to ensure that any medications affecting coagulation or blood vessels are appropriately managed before the cardiac catheterization.
C. Verify that written consent has been obtained
Verifying the presence of written consent is a critical step to confirm that the client has been adequately informed about the procedure, its risks, and benefits, and has given consent for the cardiac catheterization.
D. Check for iodine sensitivity
Checking for iodine sensitivity is important because iodinated contrast dye is commonly used during cardiac catheterization. Allergies or sensitivities to iodine contrast must be identified to prevent adverse reactions.
E. Administer all ordered oral medications
Administration of oral medications before the procedure depends on the specific medications and the healthcare provider's instructions. Some medications may be held, while others may be continued as prescribed.
Correct Answer is A
Explanation
A. Mask:
Silicosis is a lung disease caused by inhaling crystalline silica dust. The primary preventive measure during exposure to silica particles is wearing a mask or respirator. This helps to reduce the inhalation of silica dust, protecting the respiratory system.
B. Gloves: Gloves are typically worn to protect the hands and skin and are not directly related to preventing inhalation of airborne particles.
C. Eye Protection: While eye protection is important in certain occupational settings, it does not specifically address the inhalation of silica particles.
D. Gown: Gowns are worn for protection against contamination but are not directly related to the prevention of occupational lung diseases such as silicosis.
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