Davis Plus NCLEX Qs; Advanced med surg Cardiac Latest Update Graded A+

Davis Plus NCLEX Qs; Advanced med surg Cardiac Latest Update Graded A+ 1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4 pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and capillary refill time 3 seconds. *CORRECT 1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status.* 2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing. 3. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored breathing, not eupnea, which means normal breathing. 4. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status. 2. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will: 1. Be able to ambulate in the hall by date of discharge. 2. Have an audible S1 and S2 with no S3 heard by end of shift. 3. Turn, cough, and deep breathe every two (2) hours. 4. Have a pulse oximeter reading of 98% by day two (2) of care. 1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis. *CORRECT 2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure that could be life threatening.* 3. This is a nursing intervention, not a shortterm goal, for this client. 4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output. 3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which intervention should be included in the plan? Select all that apply. 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime. 1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day. *CORRECT 2. The client should not take digoxin if radial pulse is less than 60.* *CORRECT 3. The client should be on a low-sodium diet to prevent water retention.* 4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase with diuretics. 5. Instruct client to take the diuretic in the morning to prevent nocturia. 4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position. 1. Sponging the client's forehead would be appropriate, but it is not the first intervention. 2. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention. 3. Taking the vital signs would be appropriate, but it is