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:

prepare to place the client in a single room.

ask the client if they wish to speak to a spiritual advisor.

explore the possibility of suicidal thoughts with the client.

explain to the client that they will not die for a long time.

Answer and Explanation

The Correct Answer is C

A.   While privacy may be important for a patient who is emotionally distressed, the priority is addressing
the client’s emotional state, not the physical environment.
B.   This might be helpful later, but the priority is to explore the patient's feelings and concerns regarding their condition first. Immediate emotional support is more important at this stage.
C.   When a patient expresses feelings of hopelessness, as in this case, the nurse must assess for potential suicidal ideation. This is a priority to ensure patient safety and to provide necessary psychological support or intervention.
D.   While reassurance is important, providing false or unrealistic expectations can lead to further disappointment. The nurse should focus on addressing emotional distress and offering realistic support rather than giving definitive assurances.

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Correct Answer is ["B","C","D"]

Explanation

A. Fluid intake may need to be regulated in heart failure patients, consuming 2500mL of fluids per day may be too high for some patients, depending on their condition and whether they are on fluid restriction. Fluid management should be individualized, and the provider should specify the amount based on the patient's condition.
B. A low-sodium diet is essential for heart failure patients to help reduce fluid retention, decrease blood pressure, and lessen the burden on the heart. The American Heart Association recommends a sodium intake of no more than 2,000-2,300 mg per day for heart failure patients.
C. Rapid weight gain is a sign of fluid retention, which can indicate worsening heart failure. A gain of 2-3 pounds in a single day or 5 pounds in a week should prompt the client to contact their healthcare provider for further evaluation.
D. Shortness of breath with minimal activity can be a sign of worsening heart failure or fluid overload. This symptom should be reported immediately to a healthcare provider for further evaluation and possible adjustments to treatment.
E. Furosemide (a diuretic) is often prescribed to reduce fluid retention but it should not be taken without proper guidance or as a response to symptoms without consulting the healthcare provider. Taking diuretics at the wrong time or in excessive amounts can lead to dehydration and electrolyte imbalances, which could worsen the condition.

A. “I will be ready to resume participation in the football league in two weeks.! B. 'It is safe to use the microwave oven to heat up food." C. “I can use my cellphone as long as I keep it 6 inches away from the device." D. "The defibrillator will feel like a kick or blow to the chest if it fires."

Correct Answer is A

Explanation

A. This statement indicates a need for further education. After receiving an ICD, clients must refrain from engaging in vigorous physical activities such as contact sports (e.g., football) for a longer period of time to avoid injury or triggering the defibrillator. A longer recovery period is typically recommended.
B. This is correct. Microwaves do not affect the function of an ICD, so it is safe to use one.
C. This is correct. The client should keep their cellphone at least 6 inches away from the ICD to avoid interference with the device.
D. This is correct. Clients may experience a sudden, forceful sensation similar to a kick or blow when the ICD delivers a shock to correct an arrhythmia.

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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:

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Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions for the client diagnosed with heart failure. Which information should the nurse provide to assist the client to limit complications and prevent future hospitalizations? (SELECT ALL THAT APPLY).

Correct Answer is ["B","C","D"]

Explanation

The nurse has provided teaching to a client who had an implantable cardioverter/defibrillator inserted. Which statement by the client indicates the need for further instruction?

Correct Answer is A

Explanation

Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

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 client diagnosed with acute heart failure is prescribed an infusion of dopamine at a low dose. Which assessment parameter should the nurse use to best evaluate the effectiveness of this medication?

The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The nurse recognizes that which laboratory test order set will guide the provider to a diagnosis of DIC?

A patient is to receive a bolus of Heparin 20 units/kg. The patient weighs 121 Ibs. The medication is supplied as 25,000 units/250 mL. How many Ml will the nurse give? (round to the nearest whole number)

The nurse is caring for a client who received a transfusion of Fresh Frozen Plasma (FFP) for an acute GI bleed related to accidental wantarin overdose. Which laboratory result would indicate the need for an additional unit of Fresh Frozen Plasma (FFP) to correct the problem caused by the overdose?

Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?