the nurse is monitoring a client with left sided heart failure which assessment finding indicates that the clients condition is worsening
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Nursing Elites

ATI LPN

LPN Pharmacology

1. The healthcare provider is monitoring a client with left-sided heart failure. Which assessment finding indicates that the client's condition is worsening?

Correct answer: C

Rationale: Bibasilar crackles are abnormal lung sounds that indicate fluid accumulation in the lungs, a sign that left-sided heart failure is worsening. This finding suggests that the client's condition is deteriorating and requires prompt intervention to prevent further complications. Clear lung sounds (Choice A) are normal and would not indicate worsening heart failure. Increased peripheral pulses (Choice B) may be seen in conditions like anxiety or exercise, but not specifically in worsening left-sided heart failure. Improved activity tolerance (Choice D) would be a positive sign, not an indicator of worsening heart failure.

2. A client who had a myocardial infarction (MI) two days ago reports chest pain radiating to the left arm. What should the nurse do immediately?

Correct answer: B

Rationale: Obtaining an ECG is crucial in this situation because it helps in assessing for potential complications, such as a recurrent MI or ongoing ischemia. This diagnostic test provides valuable information to guide further interventions and treatment. Administering morphine, oxygen, or nitroglycerin may be necessary but obtaining an ECG takes precedence to evaluate the cardiac status and determine the appropriate course of action. Administering morphine without assessing the current cardiac status through an ECG can mask important diagnostic clues. Applying oxygen and administering nitroglycerin are supportive measures that can follow the ECG to address potential hypoxia and ischemic pain relief, respectively.

3. A healthcare professional is preparing to administer ceftriaxone 1 g IM to a client who has a pelvic infection. Which of the following actions should the healthcare professional plan to take?

Correct answer: D

Rationale: Administering ceftriaxone in a large muscle is crucial for proper absorption and to reduce the risk of pain or tissue irritation. Intramuscular administration of ceftriaxone helps achieve optimal therapeutic levels in the bloodstream for the treatment of the pelvic infection. Choices A, B, and C are incorrect. Choice A is not recommended as ceftriaxone should not be administered as a bolus over 5 minutes. Choice B is irrelevant because the question is about the administration route, not the reconstitution process. Choice C is also irrelevant as it does not pertain to the administration but to the quality of the reconstituted medication.

4. What should be the nurse's priority action when a client diagnosed with angina pectoris complains of chest pain while taking a brisk walk?

Correct answer: B

Rationale: The nurse's priority action when a client diagnosed with angina pectoris complains of chest pain while taking a brisk walk is to have the client sit down. Sitting down reduces the workload on the heart and may alleviate pain by improving oxygen supply. This action aims to reduce the strain on the heart and improve oxygen delivery to the myocardium, which can help relieve the symptoms of angina pectoris. Administering nitroglycerin could be the next step after having the client sit down if the pain persists. Obtaining an electrocardiogram and applying oxygen are not the immediate priority actions when dealing with angina pectoris symptoms.

5. A healthcare professional is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the healthcare professional include?

Correct answer: A

Rationale: Administering enoxaparin into the abdomen is recommended to ensure proper absorption and effectiveness. Massaging the injection site after administration should be avoided as it can increase the risk of bleeding or bruising. Mild bruising at the injection site is common with enoxaparin and should be expected. Alternating injection sites, especially between arms, is not suitable for enoxaparin administration. Consistent administration into the abdomen is preferred for consistent absorption of the medication.

Similar Questions

The client with a new prescription for warfarin (Coumadin) is receiving teaching from the LPN/LVN. Which statement by the client indicates an understanding of the medication?
A client with hypertension is prescribed a thiazide diuretic. What instruction should the nurse reinforce to the client?
A client with deep vein thrombosis (DVT) is receiving anticoagulant therapy. The nurse should reinforce with the client the importance of reporting which potential side effect?
A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active?
The patient with a history of myocardial infarction (MI) is prescribed aspirin. What instruction should the nurse include in the discharge teaching?

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