The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)
normal sinus rhythm that becomes sinus tachycardia
Onset of a cough with pink, frothy sputum
presence of dyspnea at rest
falls asleep when not disturbed
urine drainage is increased in amount
Correct Answer : A,B,C,D
A. Normal sinus rhythm that becomes sinus tachycardia
Sinus tachycardia can be an indication of increased sympathetic activity in response to decreased cardiac output. It may suggest the heart's compensatory response to maintain adequate perfusion.
B. Onset of a cough with pink, frothy sputum
Pink, frothy sputum is a classic sign of pulmonary edema, which can occur in the setting of worsening heart failure. It indicates the presence of blood-tinged fluid in the alveoli.
C. Presence of dyspnea at rest
Dyspnea at rest suggests that the client is experiencing difficulty breathing even without physical exertion. This can be indicative of more severe heart failure.
D. Falls asleep when not disturbed
Falling asleep when not disturbed may indicate fatigue or exhaustion, which is common in individuals with heart failure. However, it is not a direct indicator of worsening heart failure and can be influenced by various factors.
E. Urine drainage is increased in amount
Increased urine output can be a sign of diuretic therapy or an attempt by the body to compensate for fluid overload. However, it is essential to consider other factors such as renal function and medication effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["4"]
Explanation
Warfarin (Coumadin) is an anticoagulant medication that prevents blood clots from forming or growing larger. It is prescribed for clients who have atrial fibrillation, deep vein thrombosis, pulmonary embolism, or artificial heart valves.
The physician orders warfarin 10 mg PO to be administered to a client at 1800 today. The pharmacy only has 2.5 mg tablets available. To calculate the number of tablets that the nurse will administer, the nurse will divide the ordered dose by the available dose. The formula is:
Number of tablets = Ordered dose / Available dose
Number of tablets = 10 mg / 2.5 mg
Number of tablets = 4
Therefore, the nurse will administer 4 tablets of warfarin 2.5 mg PO to the client at 1800 today
Correct Answer is B
Explanation
A. Factor VIII: Factor VIII is a component of the clotting cascade, but it is not the antidote for warfarin. Factor VIII is used in the treatment of hemophilia A.
B. Vitamin K: This is the correct answer. Vitamin K is the antidote for warfarin overdose. It helps in the synthesis of clotting factors.
C. IVIG (Intravenous Immunoglobulin): IVIG is not an antidote for warfarin. It is used for various immune-related conditions.
D. Factor X: Factor X is also a clotting factor, but it is not the antidote for warfarin. Factor Xa inhibitors are used as anticoagulants.
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