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?

Correct Answer: B

Rationale: The correct answer is B because assessing the client's ability to walk upstairs without fatigue helps determine the extent of heart failure. This question assesses the client's functional capacity and exercise tolerance, which are key indicators of heart failure severity. If the client experiences fatigue while walking upstairs, it indicates decreased cardiac output and potential heart failure progression. Other choices are incorrect as they focus on symptoms (A), nocturnal dyspnea (C), and peripheral edema (D), which may be present in heart failure but do not directly assess the extent of heart failure like exercise tolerance does.

Correct Answer: A

Rationale: The correct answer is A: Allow family members to remain at the bedside. This is the priority action as it provides emotional support and comfort to the client. Having familiar faces around can help calm the client and reduce agitation. It also promotes a sense of security and connection. Choices B, C, and D are incorrect because they do not address the client's immediate need for comfort and emotional support. Asking about a fan, tuning the TV, or speaking loudly do not directly address the client's restlessness and agitation. Prioritizing the presence of family members is essential in this situation.

Correct Answer: B

Rationale: The correct answer is B: Notify the provider immediately. This is the most important action because significantly slowed drainage in a client with a chest tube after surgery can indicate a potential complication like a blocked tube or bleeding. Notifying the provider allows for prompt assessment and intervention to prevent further complications. Increasing the suction setting (choice A) without knowing the reason for slowed drainage can potentially worsen the situation. Re-positioning the chest tube (choice C) may not address the underlying issue causing the slowed drainage. Taking the tubing apart to assess for clots (choice D) should not be done by the nurse as it can introduce the risk of infection and requires sterile technique.

Correct Answer: B

Rationale: The correct answer is B (Expired food found in the refrigerator) because it poses a potential health risk to the client. Expired food can lead to foodborne illnesses, especially for an older adult post-surgery. Dirty carpets (choice A) may not directly impact the client's health. Outdated medications (choice C) can be addressed by the nurse without additional referrals. The presence of multiple cats (choice D) may be a concern for allergies or cleanliness, but it is not as urgent as expired food in terms of health risks.

Correct Answer: C

Rationale: The correct answer is C: 1630 (4:30 PM). The rationale is as follows: 1. The standard guideline for performing percutaneous coronary intervention (PCI) in acute MI is within 90 minutes of arrival at the hospital. 2. The client arrived at 1500 (3:00 PM), so adding 90 minutes to this time gives us 1630 (4:30 PM). 3. This timing aligns with The Joint Commission's Core Measures for timely PCI in acute MI cases. 4. Therefore, the correct time for the client to have PCI performed is 1630 (4:30 PM). In summary, choices A, B, and D are incorrect because they do not align with the 90-minute guideline for performing PCI in acute MI cases, as mandated by The Joint Commission's Core Measures.