Chapter 35, 36, 38 IGGY

24. The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."

C

6. A student nurse asks what "essential hypertension" is. What response by the registered nurse is best? a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." c. "It is hypertension with no specific cause." d. "It refers to severe and life-threatening hypertension."

C

11. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

A

12. A client is taking warfarin (Coumadin) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you."

A

28. A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline.

B

9. A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

D

2. A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I have been drinking more water than usual." b. "I am awakened by the need to urinate at night." c. "I must stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

c

24. A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

B

11. A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. Assess the client's respiratory status. b. Draw blood to assess the client's serum electrolytes. c. Administer intravenous furosemide (Lasix). d. Ask the client about current medications.

A

10. A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. "Could you walk further than that a few months ago?" b. "Do you walk mostly uphill, downhill, or on flat surfaces?" c. "Have you ever considered swimming instead of walking?" d. "How much pain medication do you take each day?

A

13. A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."

A

15. A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use? a. Standard Precautions b. Bleeding precautions c. Reverse isolation d. Contact isolation

A

17. A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count

A

18. A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the client's favorite channel. d. Speak loudly to the client in case of hearing problems.

A

21. A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the client's vital signs. d. Obtain consent for a central line.

A

21. A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." How should the nurse respond? a. "Would you like to talk more about this?" b. "You are lucky to have such a devoted daughter." c. "It is normal to feel as though you are a burden." d. "Would you like to meet with the chaplain?"

A

24. A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

A

25. A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

A

26. A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below: What action by the nurse is most important? a. Assess the client's blood pressure and level of consciousness. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.

A

26. A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

A

27. A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."

A

29. The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best? a. Assess the client's ankle-brachial index. b. Elevate the client's leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

A

4. A nurse is working with a client who takes atorvastatin (Lipitor). The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

A

5. A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How should the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

A

6. A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client's teaching? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."

A

7. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Women's health clinics

A

9. A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"

A

9. The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L

A

12. A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

B

23. A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store.

B

13. A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."

B

14. A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

B

14. A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

B

14. After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? a. "I'll be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by my dentist in 2 weeks." c. "I must avoid eating foods high in vitamin K, like spinach." d. "I must use an electric razor instead of a straight razor to shave."

B

15. A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

B

15. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements.

B

16. A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics.

B

16. A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.

B

16. A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases

B

17. A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

B

18. A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

B

19. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

B

2. A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."

B

20. A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

B

20. A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"

B

20. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

B

21. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.

B

22. A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching? a. "Walk until you become short of breath, and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."

B

3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. D. SUGGEST TO USE A BEDPAN

B

3. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

B

5. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take your medicine or you will get kidney failure."

B

6. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler's position.

B

7. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

B

7. After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with unlicensed assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

B

8. A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.

B

8. A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this client's discharge teaching?a. "Use a soft-bristled toothbrush and avoid flossing."b. "Avoid large crowds and people who are sick."c. "Change positions slowly to avoid hypotension."d. "Check your heart rate before taking the medication."

B

1. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

C

10. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

C

13. A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the client's sheets. c. Put on a pair of gloves. d. Assess blood pressure.

C

17. After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How should the nurse respond? a. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." b. "Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." d. "While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up."

C

22. A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

C

22. A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

C

23. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

C

1. A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

D

10. A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client's discharge teaching? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."

D

11. An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."

D

12. The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

D

19. A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How should the nurse respond? a. "Would you like to speak with a priest or chaplain?" b. "I will arrange for a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

D

19. A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants

D

2. The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

D

23. A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement? a. Apply an ice pack to the client's chest. b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on.

D

25. A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate? (Click the media button to hear the audio clip.) a. Assess for further chest pain. b. Call the Rapid Response Team. c. Have the client sit upright. d. Listen to the client's lung sounds.

D

5. A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

D

8. A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client's stress levels. d. Tell the client that anxiety is common and that you can help.

D

8. A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? a. Initiate oxygen therapy. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

D

1. A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

a

4. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. "Continue to educate the client on possible healthy changes." b. "Emphasize complications that can occur with noncompliance." c. "Tell the client that denial is normal and will soon go away." d. "You need to make sure the client understands this illness."

a

4. While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

a

3. A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."

b