NCLEX-RN
NCLEX RN Cardiovascular Questions Questions
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.
Question 1 of 5
Select the six (6) statements that the nurse should include in the teaching plan for a client with heart failure.
| You should weigh yourself every morning before breakfast |
| Report a gain of more than 2 pounds in one day. |
| It's important to limit your fluid intake to about 3 liters per day. |
| Try to include potassium-rich foods like bananas and oranges in your diet every day. |
| Avoid NSAIDs like ibuprofen unless prescribed by your provider. |
| Take frequent rest periods throughout the day and gradually increase physical activity as tolerated. |
| Reduce your sodium intake to less than 2,000 mg per day. |
Correct Answer: A,B,D,E,F,G
Rationale: Daily weighing monitors fluid status. Weight gain >2 lbs/day indicates fluid retention. C: Incorrect - Fluid restriction is typically 1.5-2 liters/day in heart failure. D: Correct - Potassium-rich foods support electrolyte balance with diuretics. E: Correct - NSAIDs can worsen heart failure. F: Correct - Rest and gradual activity prevent overexertion. G: Correct - Low sodium reduces fluid retention.
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