A patient with heart failure has tachypnea, severe dyspnea, and a SpO2 of 84%. The nurse identifies a nursing diagnosis of impaired gas exchange related to increased preload and mechanical failure. An appropriate nursing intervention for this diagnosis is

Correct Answer: D

Rationale: The correct answer is D) Place the patient in a high Fowler's position with the legs horizontal. This intervention is appropriate because positioning the patient in high Fowler's position helps to improve oxygenation by reducing pressure on the diaphragm, allowing for better lung expansion, and facilitating easier breathing. Placing the legs horizontally also promotes venous return, reducing preload on the heart and improving cardiac output. Option A) to assist the patient to cough and deep breath every 2 hours is not the most appropriate intervention for impaired gas exchange in this scenario. While coughing and deep breathing can help with lung expansion, it may not directly address the underlying issues of increased preload and mechanical failure contributing to the gas exchange problem. Option B) to assess intake and output every 8 hours and weigh daily is important for overall patient assessment and monitoring but does not directly address the immediate need for improving gas exchange in a patient with heart failure experiencing severe dyspnea and hypoxia. Option C) to encourage alternating rest and activity to reduce cardiac workload is a good general nursing intervention for patients with heart failure, but in this specific case of impaired gas exchange, the priority is to address the immediate respiratory distress and oxygenation issues. Educationally, understanding the rationale behind positioning interventions for patients with heart failure is crucial for nursing practice. Being able to connect the pathophysiology of heart failure to appropriate nursing interventions, like positioning, can significantly impact patient outcomes and quality of care.

Correct Answer: C

Rationale: In this scenario, the correct action is option C: Notify the patient's physician about the assessment data. This choice is the most appropriate because the patient's symptoms suggest a potential arterial thromboembolism originating from the left atrial thrombus. This condition requires urgent medical intervention to prevent further complications like tissue damage or limb loss. Notifying the physician promptly allows for timely evaluation and treatment. Option A (Lower the patient's left foot below heart level) is not the correct action because in the presence of arterial thromboembolism, lowering the foot could worsen the ischemia by reducing blood flow further. Elevating the extremity would be more appropriate. Option B (Administer oxygen at 4 L/minute to the patient) is not the immediate priority in this case. While oxygen may be needed eventually, addressing the acute arterial insufficiency is more urgent. Option D (Check the patient's vital signs and oximetry) is not the best next step as the clinical presentation of sudden-onset severe left foot pain, absence of a pulse, cold, and pale foot already indicates a critical situation requiring immediate medical attention. Educationally, this scenario highlights the importance of recognizing acute vascular compromise in patients with cardiac thrombi. It underscores the need for healthcare providers to act swiftly and appropriately in such emergencies to prevent serious complications and improve patient outcomes. Prompt communication with the healthcare team is crucial in ensuring timely intervention and management of potentially life-threatening conditions.

Correct Answer: B

Rationale: The correct answer is B) Chorea. Chorea is a movement disorder characterized by brief, irregular contractions that are not repetitive or rhythmic, resulting in involuntary, abrupt, rapid, non-stereotyped movements affecting multiple body regions. Chorea is a central nervous system manifestation often associated with conditions such as Huntington's disease. A) Congestive heart failure is primarily a result of the heart's inability to pump blood effectively, leading to fluid overload and subsequent symptoms like edema and shortness of breath. It is not directly related to central nervous system manifestations. C) Valve damage typically results from conditions like infective endocarditis or rheumatic fever, where the heart valves are structurally affected due to infections or autoimmune reactions. While these conditions may have some neurological symptoms, valve damage itself is not a central nervous system manifestation. D) Pericarditis is the inflammation of the pericardium, the sac surrounding the heart. It can be caused by infections, autoimmune diseases, or other underlying conditions. Though pericarditis can lead to chest pain and other symptoms, it is not a direct central nervous system manifestation. Educational context: Understanding the various manifestations of cardiovascular system disorders is crucial in clinical practice. Recognizing the different presentations helps healthcare professionals make accurate diagnoses and provide appropriate treatment. In this case, linking chorea to central nervous system involvement highlights the interconnectedness of different bodily systems and the importance of considering comorbidities in patient care.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Mitral stenosis. A P wave notch in the ECG of a client is a classic finding in mitral stenosis. When mitral stenosis is present, left atrial enlargement occurs due to the increased pressure in the left atrium. This enlargement causes a delay in the conduction of the electrical impulse through the atria, resulting in a notch in the P wave on the ECG. Now, let's analyze why the other options are incorrect: A) Aortic stenosis: Aortic stenosis typically presents with a systolic murmur and does not directly impact the P wave on an ECG. B) Mitral regurgitation: Mitral regurgitation may cause an enlarged left atrium, but it does not lead to a P wave notch on the ECG. C) Aortic regurgitation: Aortic regurgitation primarily affects the diastolic phase of the cardiac cycle and is not associated with a P wave notch. Educational context is crucial for healthcare professionals to understand the intricate details of interpreting ECG findings accurately. By grasping these nuances, healthcare providers can make informed clinical decisions and provide optimal care for patients with cardiovascular conditions. Understanding the specific ECG patterns associated with different cardiac pathologies is essential for accurate diagnosis and management.

Correct Answer: D

Rationale: In the context of the cardiovascular system exam question regarding the most common cause of dysrhythmias in a hospitalized client, the correct answer is D) Ischemic heart disease. Ischemic heart disease, such as myocardial infarction, can lead to the development of dysrhythmias due to the damage or inadequate blood supply to the heart muscle. This can disrupt the electrical conduction system of the heart, leading to abnormal heart rhythms. Option A) Hypothermia can cause dysrhythmias by slowing down the electrical impulses in the heart, but it is not as common a cause as ischemic heart disease. Option B) Metabolic acidosis can also lead to dysrhythmias by affecting the electrolyte balance in the body, but it is not as prevalent a cause as ischemic heart disease in a hospitalized client. Option C) Drug therapy can certainly contribute to dysrhythmias as a side effect of certain medications, but again, ischemic heart disease is a more common underlying cause. Educationally, understanding the relationship between ischemic heart disease and dysrhythmias is crucial for healthcare professionals caring for patients with cardiovascular conditions. Recognizing the most common causes of dysrhythmias can aid in prompt identification, appropriate treatment, and improved patient outcomes.