Cardiac custom adaptive quiz Nursing 2
A hospitalized client receiving a diet that limits sodium to 2 g complains about the bland food and refuses to eat dinner. What is an appropriate nursing response? Correct 1 Asking the client about what foods are eaten at home Incorrect 2 Telling the client about several brands of low-sodium spices 3 Explaining to the client that the diet eventually will have to be accepted 4 Urging the client to eat to become accustomed to the diet that must be followed at home
Asking the client what foods usually are eaten at home is an attempt to collect adequate data to plan the most appealing and appropriate diet. Low-sodium spices still contain salt and should be avoided when receiving a low-sodium diet. Explaining to the client that the diet eventually will have to be accepted will not guarantee compliance once the client goes home; the client has the right to accept or reject therapy. Urging the client to eat to become accustomed to the diet that must be eaten at home will not guarantee compliance once the client goes home; the client has the right to accept or reject therapy.
Which information should the nurse include when teaching a client with heart disease about cholesterol? 1. Can be found in both plant and animal sources 2. Causes an increase in serum high-density lipoprotein (HDL) 3. Should be eliminated because it causes the disease process 4. Decreases when unsaturated fats are substituted for saturated fats
Cholesterol is a sterol found in tissue; it is attributed in part to diets high in saturated fats and can be decreased with unsaturated fats. Only animal foods furnish dietary cholesterol. Exercise, not cholesterol, increases HDL levels and helps decrease the risk of heart disease. Cholesterol is also produced by the body and is needed for the synthesis of bile salts and adrenocortical and steroid sex hormones, and it should not be eliminated; cholesterol contributes to heart disease but is not the cause.
Thrombus formation is a danger for postoperative clients. Which independent interventions should the nurse perform to prevent this complication? Select all that apply. 1 Increase the client's intravenous (IV) flow rate. 2 Massage the client's extremities with lotion. 3 Place the client's legs in pneumatic stockings. Correct 4 Instruct the client to avoid crossing the legs. Correct 5 Instruct the client to dorsiflex the feet routinely.
Avoiding crossing the ankles and legs relieves pressure against the veins in the legs and facilitates venous return. Alternating planter flexion and dorsiflexion contracts calf muscles, facilitating venous return. Increasing IV fluids keeps the client hydrated, preventing dehydration and hypercoagulability; however, this is not an independent function of the nurse, because it requires a primary healthcare provider's prescription. Massaging the client's legs is contraindicated, because any developing clot could be dislodged. Placing the client's legs in pneumatic stockings is not an independent function of the nurse. The nurse needs a primary healthcare provider's prescription to apply pneumatic stockings.
A nurse is caring for a client 8 hours after surgery. The client's portable wound drainage device is half full of drainage. After emptying the drainage collection chamber, how will the nurse create negative pressure in the system? 1 Attaching the device to a wall suction unit 2 Milking the tubing toward the suction device Correct 3 Compressing the device while closing the air plug 4 Keeping the device in a position lower than the site of insertion
Compressing the device expels air in the unit, and closing the plug while it is compressed reestablishes the closed system and creates negative pressure. A portable suction device usually is not attached to a mechanical suction machine. Milking the tubing promotes patency but will not create negative pressure. Although a portable wound drainage container is kept below the level of the insertion site, which facilitates drainage by gravity, this will not create negative pressure in the system.
The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience? Correct 1 Dependent edema in the evening 2 Chest pain that decreases with rest 3 Palpitations in the chest when resting 4 Frequent coughing with yellow sputum
Decreased cardiac output causes fluid retention, which results in dependent edema; this is often noticed in the evening after the client has been standing or sitting for prolonged periods. Chest pain is indicative of cardiac ischemia. Palpitations are indicative of cardiac dysrhythmias. Coughing with yellow sputum is indicative of an infectious process in the respiratory tract; pink, frothy sputum is associated with pulmonary edema that can result from heart failure.
The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is uniquely related to heart failure? 1 "I see spots before my eyes." 2 "I am tired at the end of the day." 3 "I feel bloated when I eat a large meal." Correct 4 "I have trouble breathing when I climb a flight of stairs."
Dyspnea on exertion occurs with heart failure because of the heart's inability to meet the oxygen needs of the body. Seeing spots before one's eyes, being tired at the end of the day, and feeling bloated are not specific to heart failure
A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the primary healthcare provider probably will insert a pacemaker? 1. Angina 2. Chest pain 3. Heart block 4. Tachycardia
Heart block is the primary indication for a pacemaker because there is an interference with the electrical conduction of impulses from the atria to the ventricles of the heart. The primary treatment for angina is medication; angina is not an indication for a pacemaker. The primary treatment for chest pain is medication; chest pain is not an indication for a pacemaker. The primary treatment for tachycardia is medication; tachycardia is not an indication for a pacemaker.
The nurse is caring for a client with a history of atrial fibrillation and a diagnosis of dehydration. What does the nurse anticipate that the plan of care will include? 1 A glass of water every hour until hydrated Correct 2 Small, frequent intake of juices, broth, or milk 3 A short-term nasogastric tube for replacement of fluids and nutrients Incorrect 4 A rapid intravenous (IV) infusion of an electrolyte and glucose solution
Small, frequent intake of juices, broth, or milk will provide gradual replacement of both fluid and electrolytes without overloading the intravascular compartment. Water does not supply the necessary electrolytes, and hyponatremia may result. No data are present to indicate that the client cannot take fluids orally; a nasogastric tube is not necessary when the client can take fluids by mouth. Rapid correction of a fluid and electrolyte imbalance is dangerous; therapy should promote a gradual correction. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
During auscultation of the heart, where does the nurse expect the first heart sound (S 1) to be the loudest? 1 Base of the heart Correct 2 Apex of the heart 3 Left lateral border 4 Right lateral border
The first heart sound is produced by closure of the mitral and tricuspid valves; it is heard best at the apex of the heart. The base of the heart is where the second heart sound (S 2) is best heard; S 2 is produced by closure of the aortic and pulmonic valves. The left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. The right lateral border covers a large area; the only auscultatory area near it is the aortic area.
