Pediatric Cardiac Disorders NCLEX Questions Quizlet
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Question 1 of 5.
The client with chronic HF tells the nurse, “I get so scared at night; I wake up and feel like I can hardly breathe.†Which is the nurse's best response?
A. “You are experiencing a condition called paroxysmal nocturnal dyspnea.â€
B. “Tell me if these are related to your having vivid nightmares?â€
C. “You may be experiencing this from an increased sodium intake in your diet.â€
D. “Tell me more about how often this is occurring and how you deal with it.â€
Explanation: When the client with HF expresses concerns about breathing, the nurse should further explore the comment with an open-ended statement because more information may be gained about how the client could diminish or handle the occurrence. Naming the condition (A), assuming nightmares (B), or sodium intake (C) does not facilitate further assessment.
Question 2 of 5.
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
A. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
C. Instruct the client to remove the saltshaker from the dinner table.
D. Encourage the client to monitor urine output for change in color to become dark.
E. Discuss the importance of taking the loop diuretic furosemide at bedtime.
Explanation: Weight gain monitoring (A) detects fluid retention, pulse counting (B) ensures digoxin safety, and removing salt (C) reduces sodium intake. Dark urine (D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.
Question 3 of 5.
The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?
A. An elevated B-type natriuretic peptide (BNP).
B. An elevated creatine kinase (CK-MB).
C. A positive D-dimer.
D. A positive ventilation/perfusion (V/Q) scan.
Explanation: Elevated BNP (A) is specific to heart failure, reflecting ventricular stress. CK-MB (B) indicates myocardial infarction, D-dimer (C) suggests clotting, and V/Q scan (D) is for pulmonary embolism.
Question 4 of 5.
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
A. Assist the client to go down to the smoking area for a cigarette.
B. Transport the client to the intensive care unit (ICU) via a stretcher.
C. Provide the client going home discharge-teaching instructions.
D. Help position the client who is having a portable x-ray done.
Explanation: Positioning for an x-ray (D) is within the UAP's scope and safe. Smoking (A) is inappropriate, ICU transport (B) requires nursing judgment, and discharge teaching (C) is a nursing responsibility.
Question 5 of 5.
The nurse has written an outcome goal 'demonstrates tolerance for increased activity' for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?
A. Measure intake and output.
B. Provide two (2)g sodium diet.
C. Weigh the client daily.
D. Plan for frequent rest periods.
Explanation: Frequent rest periods (D) prevent overexertion, supporting activity tolerance in CHF. Intake/output (A), sodium diet (B), and daily weights (C) are important but less directly related to activity.
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