Question

1. A patient is admitted to the hospital with signs of low cardiac output. The nurse expects to see which of the following upon assessment?

Choose all that apply.

1. Cool, clammy extremities
2. A rash on the chest
3. Wheezes in all lung fields
4. Pallor
5. Capillary refill of 5 seconds

2. After teaching a patient with congestive heart failure (CHF), the nurse assesses the patient’s understanding. Which patient statements indicate a correct understanding of the teaching related to nutritional intake?

Choose all that apply.

1. “I’ll read the nutritional labels on food items for salt content.”
2. “I will drink at least 3 L of water each day.”
3. “Using salt in moderation will reduce the workload of my heart.”
4. “I will eat oatmeal for breakfast instead of ham and eggs.”
5. “Substituting fresh vegetables for canned ones will lower my salt intak”

3. A nurse is assessing a patient with left-sided heart failure. For which clinical manifestations would the nurse assess?

Choose all that apply.

1. Pulmonary crackles
2. Confusion, restlessness
3. Pulmonary hypertension
4. Dependent edema
5. Cough that worsens at night

4. Which statements by the patient indicate good understanding of foot care in peripheral vascular disease?

Choose all that apply.

1. “A good abrasive pumice stone will keep my feet soft.”
2. “I’ll always wear shoes if I can buy cheap flip-flops.”
3. “I will keep my feet dry, especially between the toes.”
4. “Lotion is important to keep my feet smooth and soft.”
5. “Washing my feet in room-temperature water is best.”

5. A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a patient with congestive heart failure. Which instructions would the nurse provide to the UAP when delegating care for this patient?

Choose all that apply.

1. “Reposition the patient every 2 hours.”
2. “Teach the patient to perform deep-breathing exercises.”
3. “Accurately record intake and output.”
4. “Use the same scale to weigh the patient each morning.”
5. “Place the patient on oxygen if the patient becomes short of breath.”

6. The nurse prepares to access the implanted port. The client has an intermittent cough. Which actions should the nurse take?

Choose all that apply.

1. Administer transdermal anesthetic cream 30 minutes prior to accessing the port
2. Apply clean gloves and connect the needleless connector to extension tubing on noncoring needle
3. Both client and nurse wear surgical masks during the accessing of the port
4. Use chlorhexidine swab over area of port with gentle back and forth motions over 2- to 3-in (5- to 7.5-cm) area for at least 30 seconds
5. Withdraw antimicrobial backing solution and discard before flushing port

7. A patient comes to the clinic for a routine checkup. The nurse is assessing heart failure risks. Which of the following patient characteristics put them at risk for heart failure?

Choose all that apply.

1. The patient has hypertension
2. The patient is diabetic
3. The patient has a potassium level of 4.0
4. The patient has coronary artery disease
5. The patient has a BMI of 23.8

Answer 1

1.a, d, e.

2.a, e,d..

The edema of chronic HF is often treated by dietary restriction of sodium. The patients are taught what foods are low and high in sodium and ways to enhance food flavours without the use of salt. On this diet, milk, cheese, bread, cereals, canned soups, and some canned vegetable must be severely restricted.

3.a, b

LV heaves, pulsus alternative, crackles, S3and S4 heart sounds, pleural effusion, S3and S4 sounds, changes in mental status, restlessness, confusion, weakness, fatigue, anxiety, depression, dyspnea, shallow respiration upto 32-40/ min, paroxysmsl nocturnal dyspnea, orthopnea, dry hacking cough, and nocturia.

4.c, d

Careful inspection, cleansing, and lubrication of both feet are advised to prevent cracking of the skin and infection. Soaking of the foot should be avoided.

5,a, d, c

6.b, c

Care requirements of the IV port include regular flushing. Complications attributed to implanted infusion ports include clotting, catheter migration, infection, bleeding, thrombosis, air embolism and infection at the exit site or in the pocket.

7.a, d, b.

Factors such as hypertension, diabetes, cigarette smoking, obesity, and high serum cholesterol can also contribute to the development of HF.