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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["0.75"]

Explanation

The nurse needs to calculate the correct dose of atropine for a client who has a prescription for 0.3 mg IV stat. The nurse knows that atropine is a medication that blocks the effects of the parasympathetic nervous system and is used to treat bradycardia, heart block, and some types of poisoning.

To find out how many milliliters of atropine the nurse will administer, the nurse can use the formula:

Dose ordered / Dose available = Volume to administer

Plugging in the values, the nurse gets:

0.3 mg / 0.4 mg per mL = 0.75 mL

Therefore, the nurse will administer 0.75 mL of atropine to the client IV stat.

A. “I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet.” B. “The older I get the higher my risk for peripheral arterial disease gets.” C. “Since my family is from Italy, I have a higher risk of developing peripheral arterial disease.” D. “I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels.”

Correct Answer is A

Explanation

A. “I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet.”

Explanation: This statement reflects an understanding of the association between smoking and reduced blood flow, particularly due to nicotine's vasoconstrictive effects.

B. “The older I get the higher my risk for peripheral arterial disease gets.”

Explanation: While age is a non-modifiable risk factor for PAD, it is not a statement indicating a change in behavior to address risk factors. It is correct information but doesn't involve a proactive approach to risk reduction.

C. “Since my family is from Italy, I have a higher risk of developing peripheral arterial disease.”

Explanation: Family history is a non-modifiable risk factor, and the statement correctly identifies this risk factor. However, it doesn't address modifiable factors or actions to reduce risk.

D. “I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels.”

Explanation: This statement demonstrates an understanding of a dietary modification to lower cholesterol levels, which is a positive step toward reducing a modifiable risk factor for PAD.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is ordered to receive atropine 0.3 mg IV stat. Atropine 0.4 mg per mL is available. How many milliliters will the nurse administer?

Correct Answer is ["0.75"]

Explanation

A community health nurse teaches a group of seniors at an assisted living facility about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which of the following statements?

Correct Answer is A

Explanation

A client with a complex cardiac history is scheduled for transesophageal echocardiography. Which of the following statements, if made by the nurse, is inappropriate?

A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?

The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up on this assessment finding?

The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse’s most appropriate interpretation of the chest pain?

An emergency department nurse is assessing an adult woman for a suspected myocardial infarction (MI). When planning the assessment, the nurse should be aware that female patients may have which of the following symptoms for an MI? (SELECT ALL THAT APPLY)

The nurse should place a client being admitted to the hospital with suspected tuberculosis (TB) on what type of isolation?

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)

A client has chest pain rated 8/10 as stated by the patient. The 12-lead ECG reveals ST elevation in the inferior leads and the lab results reveal cardiac enzyme levels are elevated. What is the highest priority for nursing management of this client at this time?