Question

A low-sodium diet is prescribed for a client who has fluid volume overload due to chronic heart failure. The nurse recognizes that additional teaching is necessary when the client makes which statement?

Answer 1

Correct Answers:

"l can eat whatever I want in restaurants, as long as I don't add additional salt from the shaker when the food arrives to the table."

Rationale :

🍽️Restaurant foods are often high in hidden sodium, even if no extra salt is added at the table.

🧂Processed and prepared foods in restaurants frequently contain high amounts of preservatives and seasonings that contribute to fluid retention.

🧾Clients must be taught that sodium content is not limited to visible salt, and reading menus or asking for low-sodium options is crucial.

💁‍♂️This statement shows a misunderstanding of sodium sources, indicating the need for further education on dietary sodium management in heart failure.

📌Core Message

Clients with fluid volume overload must avoid hidden sodium sources, especially in restaurant meals, regardless of adding salt at the table.

Answer 2

Correct Answers:

Laparoscopic splenectomy

Rationale :

🔪Laparoscopic splenectomy is an effective treatment in immune thrombocytopenic purpura (ITP) when medications fail, as the spleen is the primary site of platelet destruction.

🧬By removing the spleen, the lifespan of circulating platelets increases, improving platelet counts.

💊Other options such as platelet transfusions are temporary and often ineffective in ITP because the platelets are rapidly destroyed.

🏥A splenectomy provides a long-term reduction in platelet destruction for clients with chronic or refractory ITP.

📌Core Message

In refractory ITP, a splenectomy helps by removing the site of platelet destruction, leading to improved platelet survival.

Answer 3

Correct Answers:

24

Rationale :

💉To calculate the rate: (1,200 units/hr ÷ 25,000 units) × 500 mL = 24 mL/hr.

🧮This equation uses the desired dose, the available concentration, and the volume of diluent to determine the infusion rate.

📏It is essential in IV therapy to calculate dosage accurately to ensure therapeutic effect and prevent complications like bleeding.

💁‍♂️Precision in heparin administration helps manage thrombotic conditions while minimizing the risk of hemorrhage.

📌Core Message

Safe heparin infusion requires correct calculation using dose, concentration, and volume to determine mL/hr rate.

Answer 4

Correct Answers:

Transport the patient to the cardiac catheterization lab for percutaneous coronary intervention (PCI).

Rationale :

🚑An ST-elevation myocardial infarction (STEMI) with elevated troponin is a cardiac emergency requiring immediate reperfusion.

🕒The priority is to restore coronary blood flow to limit myocardial damage through PCI, ideally within 90 minutes of arrival.

💁‍♂️Other options like cardioversion, diuretics, or lipid-lowering agents do not address the acute occlusion.

⚠️Delaying PCI in STEMI can result in irreversible cardiac muscle death and significantly worsens outcomes.

📌Core Message

In STEMI, immediate PCI is the priority to restore perfusion and limit myocardial damage.

Answer 5

Correct Answers:

large von Willebrand factor molecules from your plasma.

Rationale :

🧪Thrombotic thrombocytopenic purpura (TTP) involves the accumulation of ultra-large von Willebrand factor multimers, which cause platelet clumping and small-vessel thrombosis.

💉Plasmapheresis helps by removing these large multimers and replacing deficient ADAMTS-13, the enzyme that cleaves them.

🔄This procedure significantly reduces platelet consumption and microthrombi formation.

🏥Patient education should emphasize the goal of removing the underlying pathologic factors, not just symptoms.

📌Core Message

In TTP, plasmapheresis removes large von Willebrand factor multimers to reduce platelet aggregation and thrombosis.

Answer 6

Correct Answers:

I will hold my dose and call my doctor if my heart rate is less than 60 beats per minute.
I will report any loss of appetite or nausea.

Rationale :

💁‍♂️Digoxin improves cardiac output by increasing contractility, not heart rate, making choice A incorrect.

⛔Taking a double dose after missing one increases the risk of digoxin toxicity, making C incorrect.

⌚The client correctly states to withhold the dose if the heart rate is below 60 bpm, which is a key safety measure.

🤢Loss of appetite and nausea are early signs of toxicity, and recognizing them helps prevent complications.

📌Core Message

Digoxin safety requires monitoring heart rate and recognizing early signs of toxicity like nausea and appetite loss.

Answer 7

Correct Answers:

Cardiorenal syndrome

Rationale :

🧬Cardiorenal syndrome is a condition in which heart failure impairs renal function, leading to decreased urine output and elevated creatinine.

🩸Poor cardiac output leads to reduced renal perfusion, causing progressive kidney injury.

🩺The presence of anemia further supports chronic hypoperfusion.

❌Other options like pleural effusion or HIT do not explain the renal dysfunction and laboratory findings in this client.

📌Core Message

In left-sided heart failure, reduced renal perfusion can cause cardiorenal syndrome with signs like low urine output and elevated creatinine.

Answer 8

Correct Answers:

"The purpose of this medication is to reduce the chance that I will have a stroke."

Rationale :

🧠Apixaban is an oral anticoagulant that prevents thromboembolism in patients with atrial fibrillation, thereby reducing the risk of stroke.

⚠️It does not convert the rhythm to normal (C) or control ventricular rate (B), which are managed with other medications.

💉Though it reduces clot risk, it actually increases bleeding risk, making A incorrect.

📚Clients should be educated that anticoagulation targets clot prevention, especially stroke prevention in atrial fibrillation.

📌Core Message

Apixaban reduces the risk of stroke in atrial fibrillation by preventing clot formation.

Answer 9

Correct Answers:

"If I gain 3 pounds in 2 days, i will need to restrict my calorie intake."

Rationale :

⚖️A 3-pound weight gain in 2 days is a sign of fluid retention, not increased calorie intake, and indicates possible heart failure exacerbation.

📞This requires immediate medical attention, not dietary calorie restriction.

💧Monitoring weight helps detect early fluid accumulation, a key self-care behavior in heart failure.

✅Other statements reflect good management practices like taking furosemide in the morning and limiting sodium intake.

📌Core Message

Rapid weight gain in heart failure reflects fluid overload, not calorie excess, and requires clinical attention.

Answer 10

Correct Answers:

To decrease blood pressure and reduce the workload of the heart.

Rationale :

💊Lisinopril, an ACE inhibitor, is prescribed in chronic stable angina to lower blood pressure and decrease afterload, reducing the heart's oxygen demand.

❤️This mechanism helps prevent further cardiac strain and ischemia.

❌It is not used for acute angina relief (C), nor does it directly affect cholesterol (A) or platelet function (B).

🧘By decreasing vascular resistance, lisinopril supports long-term management of angina and prevention of complications.

📌Core Message

Lisinopril helps manage chronic stable angina by lowering blood pressure and reducing cardiac workload.

1 :
A low-sodium diet is prescribed for a client who has fluid volume overload due to chronic heart failure. The nurse recognizes that additional teaching is necessary when the client makes which statement?

2 :
A nurse is caring for a client who has a diagnosis of immune thrombocytopenic purpura (ITP). Despite medication therapy, the client's platelets are low. Which of the following procedures would reduce the destruction of platelets for a client who has ITP?

5 :
A nurse is caring for a client who has been diagnosed with thrombotic thrombocytopenic purpura (TTP) and will begin plasmapheresis ment should the nurse plan to include when educating the client about this treatment?

6 :
A nurse is providing education to a client with heart failure who will begin taking digoxin daily at home. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.)

7 :
A client with a long history of poorly-managed left-sided heart failure complains of decreased urine output. Lab results show anemia and elevated serum creatinine levels. Based on these findings, which condition should the nurse suspect the client is experiencing?

8 :
A nurse is providing education before administering apixaban (Eliquis) to a client who has persistent atrial fibrillation. Which of the following statements made by the client indicates an understanding of the teaching?

9 :
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following statements made by the client requires the nurse to provide correction and additional teaching?

10 :
A client who has been diagnosed with chronic stable angina is placed on multiple medications to manage the condition. The nurse understands that the client is receiving lisinopril for which reason?

1 : A low-sodium diet is prescribed for a client who has fluid volume overload due to chronic heart failure. The nurse recognizes that additional teaching is necessary when the client makes which statement?

2 : A nurse is caring for a client who has a diagnosis of immune thrombocytopenic purpura (ITP). Despite medication therapy, the client's platelets are low. Which of the following procedures would reduce the destruction of platelets for a client who has ITP?

5 : A nurse is caring for a client who has been diagnosed with thrombotic thrombocytopenic purpura (TTP) and will begin plasmapheresis ment should the nurse plan to include when educating the client about this treatment?

6 : A nurse is providing education to a client with heart failure who will begin taking digoxin daily at home. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.)

7 : A client with a long history of poorly-managed left-sided heart failure complains of decreased urine output. Lab results show anemia and elevated serum creatinine levels. Based on these findings, which condition should the nurse suspect the client is experiencing?

8 : A nurse is providing education before administering apixaban (Eliquis) to a client who has persistent atrial fibrillation. Which of the following statements made by the client indicates an understanding of the teaching?

9 : A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following statements made by the client requires the nurse to provide correction and additional teaching?

10 : A client who has been diagnosed with chronic stable angina is placed on multiple medications to manage the condition. The nurse understands that the client is receiving lisinopril for which reason?

1 :
A low-sodium diet is prescribed for a client who has fluid volume overload due to chronic heart failure. The nurse recognizes that additional teaching is necessary when the client makes which statement?

2 :
A nurse is caring for a client who has a diagnosis of immune thrombocytopenic purpura (ITP). Despite medication therapy, the client's platelets are low. Which of the following procedures would reduce the destruction of platelets for a client who has ITP?

5 :
A nurse is caring for a client who has been diagnosed with thrombotic thrombocytopenic purpura (TTP) and will begin plasmapheresis ment should the nurse plan to include when educating the client about this treatment?

6 :
A nurse is providing education to a client with heart failure who will begin taking digoxin daily at home. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.)

7 :
A client with a long history of poorly-managed left-sided heart failure complains of decreased urine output. Lab results show anemia and elevated serum creatinine levels. Based on these findings, which condition should the nurse suspect the client is experiencing?

8 :
A nurse is providing education before administering apixaban (Eliquis) to a client who has persistent atrial fibrillation. Which of the following statements made by the client indicates an understanding of the teaching?

9 :
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following statements made by the client requires the nurse to provide correction and additional teaching?

10 :
A client who has been diagnosed with chronic stable angina is placed on multiple medications to manage the condition. The nurse understands that the client is receiving lisinopril for which reason?