ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 35 Questions
Question 1 of 5
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?
Correct Answer: A
Rationale: Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. Causes of left ventricular failure include aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.
Question 2 of 5
The presence of an S3 gallop is noted in a client. What should the nurse do?
Correct Answer: A
Rationale: The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.
Question 3 of 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?
Correct Answer: A
Rationale: Daily weights are critical for monitoring fluid retention or loss in clients with right-sided heart failure, as fluid accumulation is a key symptom of this condition. The other responses do not accurately address the purpose of daily weighing.
Question 4 of 5
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?
Correct Answer: D
Rationale: The vasodilating effects of isosorbide mononitrate frequently cause headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The headache is not related to hypoxia or dehydration, so oxygen or water would not help. Holding the medication is not warranted.
Question 5 of 5
A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching?
Correct Answer: D
Rationale: Digoxin should not be taken within 1 hour of antacids, as antacids can decrease its absorption. Holding Imdur is irrelevant to digoxin therapy. Potassium intake needs monitoring, but hypokalemia (not high potassium) is a concern with digoxin. The pulse rate threshold for holding digoxin is typically below 60 beats per minute, not 90.