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 C

Explanation

A. Hypertensive crisis is not a direct complication of atrial fibrillation. It is typically caused by uncontrolled hypertension rather than arrhythmias.
B. Cardiogenic shock can occur in severe heart failure but is not a primary complication of atrial fibrillation.
C. Embolic cerebral vascular accident (stroke) is a major risk for clients with atrial fibrillation. The irregular atrial contractions allow blood to pool in the atria, increasing the risk of clot formation. If a clot dislodges, it can travel to the brain and cause a stroke.
D. Flash pulmonary edema is a complication of acute decompensated heart failure but is not directly caused by atrial fibrillation.

A. Suggest that the client use a salt substitute. B. Obtain a blood sample for a serum sodium level. C. Advise the client to add citrus juices and bananas to her diet. D. Obtain a 12-lead ECG.

Correct Answer is D

Explanation

A. Salt substitutes often contain potassium and should be avoided in hyperkalemia.
B. While assessing other electrolytes may be useful, the immediate concern is evaluating the effects of hyperkalemia on cardiac function.
C. Citrus fruits and bananas are high in potassium and should be avoided when potassium levels are elevated.
D. A 12-lead ECG is essential to assess for cardiac dysrhythmias, as hyperkalemia can cause life-threatening arrhythmias such as peaked T waves and widened QRS complexes.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with heart failure and atrial fibrillation. The client reports feeling palpitations and shortness of breath. The nurse is aware that clients with atrial fibrillation are at risk for which complication?

Correct Answer is C

Explanation

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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?

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 caring for a client who is ordered Potassium 40 mEq IV. On hand is Potassium Chloride 20 mEq/mL. What is the nurse’s next action?

A nurse is teaching a newly licensed nurse about evaluating cardiac rhythms. Which of the following best explains calculation of the heart rate?

A nurse is caring for a client who is receiving intravenous heparin therapy for deep vein thrombosis. The nurse evaluates for side effects of this drug by observing for:

A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia. Which interventions are most appropriate and should be included in the client's plan of care? (SELECT ALL THAT APPLY)