A nurse is caring for a 74-year-old female client who reports experiencing increased shortness of breath.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Worsening of congestive heart failure is suggested by symptoms including labored breathing, coarse crackles, jugular vein distention (JVD), cool/clammy skin, and low oxygen saturation. These findings indicate pulmonary congestion due to fluid overload.
Applying O₂ at 6L/min helps improve oxygenation and alleviate respiratory distress. Lower-flow oxygen (such as 2L/min) may not be sufficient in acute heart failure exacerbation.
Monitoring respiratory rate is essential to track breathing effort and response to treatment.
Monitoring oxygen saturation helps assess oxygenation status and effectiveness of interventions.
Smoking cessation is important for long-term lung and cardiovascular health but does not address the acute issue.
WBC count and temperature are more relevant to infections like pneumonia rather than acute heart failure.

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Correct Answer is B

Explanation

A. A weight gain of 1 lb in a week may not indicate fluid overload, but a more rapid increase is concerning.
B. A weight gain of 2 lbs in 24 hours or 5 lbs in a week suggests worsening heart failure due to fluid retention, requiring immediate provider notification.
C. Daily weights should be taken at the same time each day, preferably in the morning, after urination and before eating, for accurate monitoring.
D. Skipping a diuretic dose can lead to fluid retention and worsening symptoms, so adherence to the medication regimen is crucial.

A. Dyspnea B. Anorexia C. Malaise D. Fever

Correct Answer is A

Explanation

A. Dyspnea is the priority finding as it may indicate heart failure or pulmonary embolism, both of which are life-threatening complications of infective endocarditis.
B. Anorexia is a common symptom but is not an immediate threat to the client's condition.
C. Malaise is a general symptom of infection but does not require urgent intervention.
D. Fever is a hallmark sign of infection but is not as critical as assessing for complications such as heart failure or embolic events.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client diagnosed with infective endocarditis. The nurse is aware that which of the following is the priority assessment finding for this patient?

Correct Answer is A

Explanation

A nurse is caring for a client post-transcatheter aortic valve replacement (TAVR). During the first cardiac rehabilitation session, the client tells the nurse, "I do not need to be here. I am feeling so much better, I can do this at home." Which of the following is the appropriate nursing response?

A nurse is caring for a client with an acute myocardial infarction (AMI). The nurse is preparing medications for the client and recognizes that which medication will dilate the client’s coronary blood vessels?

A nurse is caring for a client with heart failure (HF) and preparing to give a daily dose of Digoxin (Lanoxin). The nurse understands the rationale for giving this medication for HF is which of the following?

A nurse is caring for a client who is having an acute myocardial infarction (MI). The nurse is aware that which of the following are part of the assessment of cardiac pain? (SELECT ALL THAT APPLY).

A nurse is providing discharge instructions for a client diagnosed with congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

A nurse is caring for a client with heart failure who takes furosemide (Lasix) 20 mg daily at home and is receiving 40 mg of furosemide (Lasix) IV daily in the hospital. The nurse is aware that this patient is at risk for which electrolyte imbalance?