Exam for RN Cardiovascular NCLEX Exam
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Question 1 of 5.
Extract:The following scenario applies to the next 6 items The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. Item 1 of 6 History And Physical Nurses' Notes Flow Sheet 0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
Which findings suggest a worsening of the client's condition and warrant follow-up by the nurse for a client presenting with shortness of breath and heart failure? Select all that apply.
A. Describes increasing shortness of breath over the past 2 days
B. States, 'I feel like I can't catch my breath'
C. Mentions needing to sleep in a recliner to breathe comfortably
D. Notes a 4-pound weight gain over the past week
E. Exhibiting use of accessory muscles during respiration
F. Auscultation reveals bilateral crackles in the lungs
G. Reports orthopnea and episodes of paroxysmal nocturnal dyspnea
Explanation: All findings indicate worsening heart failure: A, B, C, G - Shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea suggest pulmonary congestion. D: Weight gain indicates fluid retention. E: Accessory muscle use shows respiratory distress. F: Crackles indicate pulmonary edema.
Question 2 of 5.
The nurse is caring for a client following a femoral angiography. When developing this client's plan of care, the nurse plans to
A. encourage the client to ambulate within one hour following this procedure.
B. discontinue prescribed intravenous fluids immediately after the procedure
C. assess kidney function via lab testing on the day following the procedure.
D. maintain nothing by mouth (NPO) status for 4 hours following the procedure.
Explanation: Femoral angiography involves contrast dye, which can affect kidney function. Monitoring renal function via lab tests (e.g., creatinine) post-procedure is essential to detect contrast-induced nephropathy.
Question 3 of 5.
The nurse is caring for a client with myocardial infarction (MI), who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following?
A. Observe for neurological changes
B. Monitor for any signs of renal failure
C. Observe for signs of bleeding
D. Check the client's food diary
Explanation: tPA is a thrombolytic that increases bleeding risk. Monitoring for signs of bleeding (e.g., hematoma, gastrointestinal bleeding) is critical.
Question 4 of 5.
The nurse is assessing a client with clinical manifestations of right ventricular heart failure (HF). Which of the following statements by the client would be consistent with this diagnosis?
A. I notice that my feet are always swollen.
B. I can't seem to get rid of this wet cough.
C. I develop shortness of breath after I walk a few feet.
D. My legs start to burn if I walk long distances.
Explanation: Right ventricular heart failure causes systemic venous congestion, leading to peripheral edema, such as swollen feet.
Question 5 of 5.
The nurse is caring for a client who is reporting pain in their left lower leg. How should the nurse assess for the presence of thrombophlebitis?
A. By palpating the skin over the tibia and fibula
B. By documenting daily calf circumference measurements
C. By recording vital signs obtained four times a day
D. By noting difficulty with ambulation
Explanation: Measuring calf circumference detects swelling, a key sign of thrombophlebitis, indicating possible deep vein thrombosis.
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