Which clinical manifestation would the nurse use to best indicate that the status of an elderly client's chronic heart failure condition is Improving?

Heart rate 100 beats per minute

+ 3 peripheral edema

Respiratory rate of 24 at rest

Alert and oriented X 3

Answer and Explanation

The Correct Answer is D

A.   A heart rate of 100 beats per minute is considered tachycardia (a heart rate above 100 bpm). This is not an indicator of improvement in heart failure, as it suggests the heart is working harder than usual. Chronic heart failure can lead to compensatory mechanisms such as tachycardia, but it’s typically not a sign of improvement.
B.   Peripheral edema (swelling in the legs, ankles, or feet) is a common symptom of heart failure, resulting from fluid buildup due to poor cardiac output. A rating of +3 edema indicates moderate to severe swelling, which suggests fluid retention and poor circulation. This is a sign of worsening or poorly controlled heart failure, not improvement.
C.   A respiratory rate of 24 breaths per minute is slightly elevated, as the normal resting respiratory rate for adults is typically between 12 to 20 breaths per minute. A higher respiratory rate can be a sign of respiratory distress or compensatory breathing due to insufficient oxygenation or fluid buildup in the lungs (pulmonary edema), which are both symptoms of heart failure exacerbation.
D.   Being alert and oriented X 3 means the client is aware of time, place, and person, indicating no signs of confusion or cognitive impairment. In the context of chronic heart failure, mental status changes (like confusion or disorientation) can occur due to decreased cerebral perfusion, low oxygen levels, or medications (such as diuretics or digitalis.

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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. weigh daily on the same scale at the same time of day B. restrict foods that are high in potassium. C. engage in aerobic activity for one hour each day. D. monitor sugar intake

Correct Answer is A

Explanation

A. Weigh daily on the same scale at the same time of day - Daily weight measurement is critical for clients with heart failure to monitor for fluid retention, which can indicate worsening heart failure.
B. Restrict foods that are high in potassium - This is not recommended unless the client is on certain medications (e.g., potassium-sparing diuretics) that cause high potassium levels. Generally, potassium- rich foods are beneficial for heart health.
C. Engage in aerobic activity for one hour each day - Although exercise is important, the intensity and duration should be individualized, and clients with heart failure may need to start with lower-intensity activity.
D. Monitor sugar intake - While important for diabetes management, monitoring sugar intake is not a primary focus for clients with heart failure unless they also have diabetes.

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LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL
Calcium	8.0 mg/dL	8.2-10.2 mg/dL:

			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

Which clinical manifestation would the nurse use to best indicate that the status of an elderly client's chronic heart failure condition is Improving?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When using an ECG rhythm strip to quickly estimate the ventricular rate for a client, the nurse should:

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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