Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has heart failure.
Which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation?
A. "I will weigh myself daily.".
Choice A is not the correct answer because weighing oneself daily is a recommended self-monitoring technique for clients with heart failure.
B. "l hate how I feel all the time.".
Choice B is not the correct answer because while feeling unhappy can be a symptom of heart failure, it does not necessarily indicate a need for cardiac rehabilitation.
C. "I'm too tired to brush my teeth.".
“I’m too tired to brush my teeth.” This statement indicates that the client is experiencing fatigue, which is a common symptom of heart failure. Fatigue can significantly impact a person’s ability to perform daily activities and can be an indication that the client needs a referral for cardiac rehabilitation 1.
D. "I need to start eating a low-sodium diet.".
Choice D is not the correct answer because eating a low-sodium diet is a recommended dietary change for clients with heart failure.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
“I’m too tired to brush my teeth.” This statement indicates that the client is experiencing fatigue, which is a common symptom of heart failure.
Fatigue can significantly impact a person’s ability to perform daily activities and can be an indication that the client needs a referral for cardiac rehabilitation 1.
Choice A is not the correct answer because weighing oneself daily is a recommended self-monitoring technique for clients with heart failure.
Choice B is not the correct answer because while feeling unhappy can be a symptom of heart failure, it does not necessarily indicate a need for cardiac rehabilitation.
Choice D is not the correct answer because eating a low-sodium diet is a recommended dietary change for clients with heart failure.
Similar Questions
A nurse is caring for a client who has cancer. The client tells the nurse, "I would prefer to try vitamins and minerals instead of chemotherapy." Which of the following responses should the nurse make?
A. "You should ask your provider about your plan.".
This response is appropriate because it acknowledges the client's desire to explore alternative treatments while directing them to the appropriate source for medical advice. It promotes client autonomy and ensures they receive accurate information from their healthcare provider.
B. "Tell me what you know about chemotherapy.".
This response is also appropriate. It encourages the client to express their understanding and concerns about chemotherapy, allowing the nurse to identify any misconceptions and provide accurate information. This also opens the door for the client to express their concerns about vitamins and minerals, and why they want to persue that treatment.
C. "I have never heard of any holistic treatment that is effective.".
This response is inappropriate because it dismisses the client's preferences and demonstrates a lack of respect for their autonomy. It also displays a lack of knowledge, as some holistic treatments can be used as supportive therapies.
D. "The best way to treat your cancer is chemotherapy.".
This response is inappropriate because it is directive and does not allow the client to participate in decision-making. It also does not address the client's desire to explore alternative treatments.
Full Explanation
- A. "You should ask your provider about your plan." This response is appropriate because it acknowledges the client's desire to explore alternative treatments while directing them to the appropriate source for medical advice. It promotes client autonomy and ensures they receive accurate information from their healthcare provider.
- B. "Tell me what you know about chemotherapy." This response is also appropriate. It encourages the client to express their understanding and concerns about chemotherapy, allowing the nurse to identify any misconceptions and provide accurate information. This also opens the door for the client to express their concerns about vitamins and minerals, and why they want to persue that treatment.
- C. "I have never heard of any holistic treatment that is effective." This response is inappropriate because it dismisses the client's preferences and demonstrates a lack of respect for their autonomy. It also displays a lack of knowledge, as some holistic treatments can be used as supportive therapies.
- D. "The best way to treat your cancer is chemotherapy." This response is inappropriate because it is directive and does not allow the client to participate in decision-making. It also does not address the client's desire to explore alternative treatments.
A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning.
The nurse should recognize these assessment findings as indicating which of the following?
A. Increased cardiac output.
Choice A is not the correct answer because the increased cardiac output would not cause these symptoms.
B. Pleural effusion.
Choice B is not the correct answer because pleural effusion refers to a buildup of fluid between the layers of tissue that line the lungs and chest cavity, which would not cause these symptoms.
C. Fluid volume excess.
“Fluid volume excess.” Bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning are all signs of fluid volume excess. Fluid volume excess can occur when the heart is unable to pump blood efficiently, causing fluid to build up in the lungs.
D. Aspiration.
Choice D is not the correct answer because aspiration refers to the inhalation of food, liquid, or other substances into the lungs, which would not cause these symptoms.
Full Explanation
“Fluid volume excess.” Bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning are all signs of fluid volume excess.
Fluid volume excess can occur when the heart is unable to pump blood efficiently, causing fluid to build up in the lungs.
Choice A is not the correct answer because the increased cardiac output would not cause these symptoms.
Choice B is not the correct answer because pleural effusion refers to a buildup of fluid between the layers of tissue that line the lungs and chest cavity, which would not cause these symptoms.
Choice D is not the correct answer because aspiration refers to the inhalation of food, liquid, or other substances into the lungs, which would not cause these symptoms.
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia.
Which of the following assessment findings requires immediate intervention by the nurse?
A. The client's capillary refill in the left toe is 6 seconds.
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin. A normal capillary refill time is less than 2 seconds. A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
B. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
C. The client has an oral temperature of 38.3° C (100.9° F).
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
D. The client has 100 mL of blood in the closed-suction drain.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Full Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.