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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Obtain a sputum sample:

This option is more relevant when the client is experiencing cough with sputum production, which might suggest respiratory issues. However, in the context of coughing after eating or drinking, the primary concern is likely related to the swallowing process rather than respiratory conditions.

B. Inspect the client’s tongue and mouth:

While inspecting the tongue and mouth is a good practice for assessing oral health, it may not directly address the issue of coughing after eating or drinking, which is more indicative of potential swallowing difficulties.

C. Perform a swallowing assessment:

This is the most appropriate option for the given scenario. A swallowing assessment helps identify any abnormalities or difficulties in the swallowing process, which could contribute to the client's coughing after eating or drinking.

D. Assess the client’s nutritional status:

While assessing nutritional status is important for overall health, it may not directly address the immediate concern of coughing after eating or drinking. Nutritional status assessment is a broader aspect of care.

A. Frequent change of position B. Antibiotics C. Oxygen humidification D. Chest physiotherapy

Correct Answer is A

Explanation

A. Frequent change of position:

Frequent changes in position help prevent pooling of secretions and promote lung expansion. This simple and cost-effective measure is important in preventing complications related to immobility, such as pneumonia and atelectasis. It aids in maintaining optimal respiratory function.

B. Antibiotics: Antibiotics are used to treat bacterial infections and would not directly address the risks associated with decreased mobility.

C. Oxygen humidification: While oxygen therapy may be necessary in some cases, humidification is typically used to prevent drying of mucous membranes and is not a primary intervention for preventing complications of decreased mobility.

D. Chest physiotherapy: Chest physiotherapy involves techniques to mobilize respiratory secretions and may be indicated in specific situations. However, it is not as simple and cost-effective as frequent changes in position.

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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)

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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