The nurse is developing a plan of care for a client with cardiovascular disease who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

The nurse will instruct client's family members about the prescribed diet.

The client's daily blood pressure will be less than 140/80 mm Hg this month.

The nurse will encourage the client to walk thirty minutes every day.

The client's family will state signs and symptoms about the disease.

Answer and Explanation

The Correct Answer is B

Angina pectoris manifests as myocardial ischemia when oxygen demand exceeds supply during physical activity or emotional stress. Management requires hemodynamic stabilization to reduce afterload and myocardial workload, preventing progress to myocardial infarction or chronic heart failure through strict adherence to therapeutic mean arterial pressure targets and lifestyle modifications.

Rationale:

A. Educating family members represents a nursing intervention rather than a measurable client-centered outcome. Plans of care must focus on the patient's response to treatment and specific physiological or behavioral changes. While family support is vital, it does not directly quantify the clinical status of the patient’s cardiovascular health.

B. This choice provides a measurable goal with a specific physiological parameter and timeframe for evaluation. Maintaining a blood pressure below 140/80 mm Hg reduces ventricular wall tension and oxygen consumption in the myocardium. It serves as a objective clinical indicator that the cardiovascular disease is being managed effectively.

C. Encouraging a client to exercise is a nursing action meant to improve long-term cardiovascular endurance and lipid profiles. An outcome must be phrased to show what the client achieves, such as the client successfully completing exercise without anginal symptoms. It lacks the specific measurability required for a formal nursing diagnosis outcome.

D. Having the family state symptoms is a learning objective that evaluates the effectiveness of the nurse's teaching plan. It does not address the client's physical condition or the primary complaint of chest pain on exertion. Outcomes should prioritize the physiological stability and symptom management of the individual patient in the clinical setting.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Brief introduction:

Central line-associated bloodstream infections result from pathogen colonization of the catheter tip or hub. Daily assessments facilitate early catheter removal to eliminate the primary mechanical nidus for bacterial entry. Maintenance of sterile barriers is critical for preventing healthcare-acquired sepsis.

Rationale:

A. Aseptic technique is mandatory for every access event, not just specific ports. Routine scrubbing of the hub for 15 seconds prevents intraluminal contamination during medication administration or fluid changes. This action is a constant requirement rather than a specific daily bundle intervention.

B. Flushing the lumen maintains patency but does not directly address the daily infection prevention bundle. Regular pulsatile flushing prevents fibrin tail formation, which can trap bacteria. While necessary for catheter function, it is not the primary daily assessment for infection reduction.

C. Daily review of line necessity is the most effective way to prevent infection. Eliminating the vascular access device as soon as clinically possible removes the portal of entry for staphylococcal species. Clinical guidelines prioritize prompt removal over all other maintenance interventions for risk mitigation.

D. Transparent dressings should be changed every 7 days or if they become damp, loose, or soiled. Frequent dressing disruptions can actually increase the risk of introducing epidermal flora into the insertion site. Daily changes are contraindicated unless the integrity of the dressing is compromised.

A. Sinus tachycardia B. Potassium level decreased C. Urine clear yellow D. Decreased respiratory rate E. Urine output of 0.5 mL/kg in an hour F. Lungs clear to auscultation G. Nasal flaring H. Improved oxygen saturation

Correct Answer is ["D","F","H"]

Explanation

Patent ductus arteriosus (PDA) in preterm infants involves a failure of the ductus arteriosus to close, leading to a left-to-right shunt. This abnormal flow increases pulmonary blood volume, resulting in pulmonary congestion, interstitial edema, and increased work of breathing. Furosemide, a potent loop diuretic, is administered to reduce circulatory preload and mobilize fluid from the lungs, thereby improving alveolar gas exchange and reducing the physical signs of respiratory distress.

Rationale:

A. Sinus tachycardia is an adverse effect or a sign of compensatory distress, not an intended therapeutic effect of furosemide. While diuretics can cause volume depletion leading to a rapid heart rate, the goal of treatment is to stabilize the infant’s hemodynamics. Successful diuresis should ideally reduce the workload on the heart, leading to a more stable, normal cardiac rhythm.

B. A decreased potassium level is a common adverse complication of loop diuretics rather than a desired therapeutic goal. Furosemide inhibits the sodium-potassium-chloride symporter in the thick ascending limb of the loop of Henle, leading to significant kaliuresis. While expected, hypokalemia must be carefully monitored and managed to prevent cardiac arrhythmias in a vulnerable neonate.

C. Urine color is not a primary indicator of furosemide efficacy in the context of treating pulmonary congestion. While diuresis will occur, the clarity or hue of the urine does not confirm that pulmonary edema has been resolved. The nurse focuses on the volume of output and the subsequent improvement in respiratory status rather than the visual characteristics of the void.

D. A decreased respiratory rate indicates that pulmonary compliance has improved following the removal of excess interstitial fluid. As furosemide reduces pulmonary vascular congestion, the infant no longer needs to use accessory muscles or breathe rapidly (tachypnea) to maintain gas exchange. This shift toward a normal respiratory rate of 30 to 60 breaths/minute is a key sign of effective treatment.

E. Urine output of 0.5 mL/kg in an hour is actually below the minimum expected range for a neonate, especially after receiving a diuretic. Normal neonatal output should be 1 to 3 mL/kg/hour; therefore, 0.5 mL/kg/hour would suggest inadequate renal response or potential dehydration. The intended effect of furosemide is robust diuresis that exceeds baseline maintenance output.

F. Lungs becoming clear to auscultation is a direct result of fluid mobilization out of the pulmonary parenchyma. The diffuse fluid noted on the initial chest x-ray should decrease, leading to the disappearance of adventitious sounds like crackles or moist rales. Clear lung fields confirm that the diuretic has successfully reduced the pulmonary edema caused by the PDA shunt.

G. Nasal flaring is a classic sign of respiratory distress and increased work of breathing in a newborn. If furosemide is effective, this clinical finding should disappear as the airway resistance decreases and lung expansion becomes easier for the infant. The persistence of nasal flaring would indicate that the diuretic therapy has not yet achieved its intended respiratory goals.

H. Improved oxygen saturation is an expected outcome as alveolar ventilation is restored and the ventilation-perfusion mismatch is corrected. By removing the fluid barrier between the alveoli and the capillaries, furosemide allows for more efficient oxygen diffusion. This leads to higher systemic saturation levels, potentially allowing for a weaning of the supplemental oxygen hood.

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 is developing a plan of care for a client with cardiovascular disease who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Correct Answer is C

Explanation

Correct Answer is ["D","F","H"]

Explanation

After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health. Which type of activity should the nurse include in the teaching?

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?

The nurse uses the Fulmer SPICES system with an older adult client. When assessing for the "C" in SPICES, which problem is the nurse assessing?

The nurse is providing discharge instructions to a client with atopic dermatitis who received a prescription for dexamethasone 8 mg PO daily. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

A client with advanced cirrhosis is being treated for hepatic encephalopathy. In reviewing the client's serum laboratory results, which finding requires the most immediate intervention by the nurse?

The nurse is developing a plan of care for a client with cardiovascular disease who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

A client recently diagnosed with Hodgkin's disease undergoes biopsy of cervical lymph nodes under local anesthesia. Which intervention is most important to include in this client's plan of care?