The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

"How many pillows do you sleep on mister"

"Do you have chest pain when you walk up the steps?"

"Do you find that your rings and shoes feel tight at the end of the day?"

"How many times do you get up to void at night?"

Answer and Explanation

The Correct Answer is A

A.   This question assesses the client's level of orthopnea, which is a condition where the client experiences difficulty breathing when lying flat. People with heart failure may need to use multiple pillows to prop themselves up to breathe more easily at night, making it an important question to assess respiratory status.
B.   Chest pain with exertion can be indicative of cardiovascular issues but this question does not directly assess the client's respiratory status.
C.   Tight rings and shoes can indicate fluid retention and edema, but it does not provide specific information about respiratory status.
D.   Frequent nighttime voiding (nocturia) is common in heart failure, but it relates more to kidney function and fluid retention rather than respiratory function.

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 {"dropdown-group-1":"C","dropdown-group-2":"D","dropdown-group-3":"D"}

Explanation

Atrial fibrillation: This is a common arrhythmia where the atria quiver instead of contracting normally, leading to irregular heart rhythms.

Amiodarone- an antiarrhythmic medication may be used to control the heart rate or rhythm in atrial fibrillation.

Heparin-an anticoagulant prevent thromboembolic events, such as stroke, anticoagulants like heparin, enoxaparin, or newer agents like rivaroxaban are used.

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.

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 performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D","dropdown-group-3":"D"}

Explanation

The nurse is planning care for a client diagnosed with heart failure who will soon be discharged home. What should be included in the teaching plan? The client will:

Correct Answer is A

Explanation

The nurse is caring for a client diagnosed with disseminated intravascular coagulation (DIC). When completing an assessment for decreased perfusion from clotting, the nurse would observe for which manifestation?

The nurse is evaluating the following rhythm strip on a client in the telemetry unit. The client is alert and oriented but complains of slight nausea after eating breakfast. What is the nurse's best action?

The nurse is preparing to start a transfusion of packed red blood cells for a client with a hemoglobin of 5.4 g/dL. (normal Female: 11.7-15.5 g/dL; Male: 14-17.3 g/dL). Which IV site should the nurse use?

The nurse is caring for a client diagnosed with acute heart failure on the telemetry unit. Which laboratory result does the nurse know is most indicative of this diagnosis?

The client with heart failure exhibits bibasilar crackles, dyspnea and a respiratory rate of 26/min. The physician prescribes furosemide 40 mg IV. Which parameter would the nurse use to best evaluate if the client is responding to this medication?

Which physical assessment findings would the nurse anticipate for a client with rapid atrial flutter?

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to: