the nurse notes that a client with a history of left sided heart failure exhibits increasing shortness of breath and frothy sputum what is the priorit
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Nursing Elites

ATI LPN

LPN Pharmacology Assessment A

1. The client with a history of left-sided heart failure is exhibiting increasing shortness of breath and frothy sputum. What is the priority nursing action?

Correct answer: A

Rationale: Shortness of breath and frothy sputum are indicative of pulmonary edema, a serious condition that requires immediate intervention to improve oxygenation. Administering oxygen is the priority action to support the client's respiratory function and prevent further deterioration. Oxygen therapy helps increase the oxygen levels in the blood, alleviate respiratory distress, and support vital organ function. Prompt intervention with oxygen can help stabilize the client while further assessments and treatments are initiated. Encouraging coughing and deep breathing may worsen the client's condition by increasing respiratory effort. Placing the client in a supine position can further compromise breathing in a client with pulmonary edema. Notifying the healthcare provider is important but not the priority when the client's respiratory status is deteriorating.

2. When assisting a hospitalized client newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu, which meal should the nurse encourage the client to select?

Correct answer: D

Rationale: The correct choice is D: Fresh strawberries, steamed vegetables, and baked fish. This meal is low in saturated fats and cholesterol, which is suitable for a client with CAD. It aligns with dietary recommendations to support heart health and manage CAD. Choices A, B, and C are less appropriate as they contain higher levels of saturated fats and cholesterol, which are not ideal for individuals with CAD.

3. A client has a new prescription for nitroglycerin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: Instructing the client to take nitroglycerin at the first sign of chest pain is crucial for immediate relief of angina symptoms. Nitroglycerin is a fast-acting medication that helps dilate blood vessels, improving blood flow to the heart muscle. Therefore, prompt administration at the onset of chest pain is essential to alleviate anginal episodes effectively. Choices A, B, and C are incorrect because storing the medication properly, taking it as directed, or before meals are not specific instructions for managing acute anginal episodes, which require immediate action for symptom relief.

4. The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?

Correct answer: B

Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings. Shaving the front of the client's chest is unnecessary and not a standard practice for Holter monitor placement. Instructing the client to rest as much as possible does not promote normal daily activities which are important for accurate monitoring. Covering the monitor in plastic wrap before bathing is not recommended as it may affect the functionality of the device.

5. An ambulatory clinic nurse is interviewing a client who is complaining of flu-like symptoms. The client suddenly develops chest pain. Which question best assists the nurse in discriminating pain caused by a non-cardiac problem?

Correct answer: C

Rationale: The correct answer is C. Pain that worsens with breathing in can indicate pleuritic chest pain, which is non-cardiac in nature. This specific question helps in differentiating non-cardiac causes from cardiac causes of chest pain, as cardiac pain typically does not worsen with breathing. Choices A, B, and D are less specific in discriminating between cardiac and non-cardiac chest pain.

Similar Questions

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 nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. What intervention should the nurse do to effectively accomplish this goal?
The client admitted to the hospital with pulmonary edema is preparing for discharge. The client should be reminded of the importance of complying with which measure to prevent a recurrence?
A client with a history of heart failure is being discharged with a prescription for digoxin (Lanoxin). The nurse should include which instruction in the discharge teaching?
During an assessment, a client taking valproic acid exhibits elevated liver enzymes. What finding should the nurse report to the provider?

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