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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. “I will have canned chicken noodle soup with crackers and an apple for lunch.”

This option may not be the best choice for a low-sodium diet. Canned soups often contain high levels of sodium.

B. “I will have a tossed salad with cheese and croutons for lunch.”

This option is a better choice, as salads with fresh vegetables can be lower in sodium compared to other options.

C. “I will have a ham and cheese sandwich for lunch.”

Ham and cheese are generally high in sodium, so this would not be a suitable choice for a low-sodium diet.

D. “I will have a baked potato with broiled chicken for dinner.”

This option seems to be a good choice. Baked potato and broiled chicken can be part of a low-sodium meal.

A. Frequent change of position B. Antibiotics C. Oxygen humidification D. Chest physiotherapy

Correct Answer is A

Explanation

A. Frequent change of position:

Frequent changes in position help prevent pooling of secretions and promote lung expansion. This simple and cost-effective measure is important in preventing complications related to immobility, such as pneumonia and atelectasis. It aids in maintaining optimal respiratory function.

B. Antibiotics: Antibiotics are used to treat bacterial infections and would not directly address the risks associated with decreased mobility.

C. Oxygen humidification: While oxygen therapy may be necessary in some cases, humidification is typically used to prevent drying of mucous membranes and is not a primary intervention for preventing complications of decreased mobility.

D. Chest physiotherapy: Chest physiotherapy involves techniques to mobilize respiratory secretions and may be indicated in specific situations. However, it is not as simple and cost-effective as frequent changes in position.

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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)

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Naxlex Comprehensive Predictor Exams

A client with heart failure is placed on a low sodium diet. Which statement by the client indicates that the nurse’s nutritional teaching plan has been effective?

Correct Answer is B

Explanation

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

Correct Answer is A

Explanation

An older adult is newly diagnosed with primary hypertension, and has just been started on a beta-blocker. What information should the nurse include in the health education for this client?

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)

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