Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client in the outpatient cardiologist's office. The client is alert and oriented. Lung sounds with crackles are heard bilaterally. Dyspnea is observed on exertion, and heart sounds reveal an S3 gallop. Which of the following findings is the nurse most likely to expect?
A. Elevated blood pressure
Elevated blood pressure is a common finding in cardiovascular conditions but is not specifically indicated by the presence of crackles, dyspnea on exertion, or an S3 gallop.
B. Decreased respiratory rate
A decreased respiratory rate is not typically associated with the presence of crackles and dyspnea; these symptoms are more indicative of increased work of breathing and potential fluid overload.
C. Pitting edema
Pitting edema is a classic sign of fluid retention, which can be associated with heart failure. The presence of crackles, dyspnea on exertion, and an S3 gallop are clinical indicators that suggest heart failure, making pitting edema a likely finding.
D. Irregular pulse
An irregular pulse may be found in various cardiac conditions but is not directly suggested by the symptoms described. The presence of an S3 gallop is more indicative of heart failure, which is commonly associated with fluid overload signs such as pitting edema.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Proctored Exam Midterm Rn 36 1125. Take the full exam now
Full Explanation
Choice A rationale
Elevated blood pressure is a common finding in cardiovascular conditions but is not specifically indicated by the presence of crackles, dyspnea on exertion, or an S3 gallop.
Choice B rationale
A decreased respiratory rate is not typically associated with the presence of crackles and dyspnea; these symptoms are more indicative of increased work of breathing and potential fluid overload.
Choice C rationale
Pitting edema is a classic sign of fluid retention, which can be associated with heart failure. The presence of crackles, dyspnea on exertion, and an S3 gallop are clinical indicators that suggest heart failure, making pitting edema a likely finding.
Choice D rationale
An irregular pulse may be found in various cardiac conditions but is not directly suggested by the symptoms described. The presence of an S3 gallop is more indicative of heart failure, which is commonly associated with fluid overload signs such as pitting edema.
Similar Questions
A nurse is planning care for a client who has atrial fibrillation and reports heart palpitations, lightheadedness, and shortness of breath. Which of the following procedures should the nurse anticipate for this client?
A. Pericardiocentesis
Pericardiocentesis is a procedure used to remove fluid from the pericardial sac and is not typically used to treat atrial fibrillation. It is more commonly indicated for conditions such as pericardial effusion or cardiac tamponade.
B. Septal myectomy
Septal myectomy is a surgical intervention to remove part of the thickened septal wall that separates the ventricles of the heart. It is primarily used to treat hypertrophic cardiomyopathy, not atrial fibrillation.
C. Pericardial window
A pericardial window is a procedure that creates an opening in the pericardium to allow fluid to drain into the surrounding chest cavity. This procedure is not a treatment for atrial fibrillation.
D. Synchronized electrical cardioversion
Synchronized electrical cardioversion is a procedure where a controlled electric shock is delivered to the heart to restore a normal rhythm. It is a common and effective treatment for atrial fibrillation, especially when the condition is causing significant symptoms like palpitations, lightheadedness, and shortness of breath.
Full Explanation
Choice A rationale
Pericardiocentesis is a procedure used to remove fluid from the pericardial sac and is not typically used to treat atrial fibrillation. It is more commonly indicated for conditions such as pericardial effusion or cardiac tamponade.
Choice B rationale
Septal myectomy is a surgical intervention to remove part of the thickened septal wall that separates the ventricles of the heart. It is primarily used to treat hypertrophic cardiomyopathy, not atrial fibrillation.
Choice C rationale
A pericardial window is a procedure that creates an opening in the pericardium to allow fluid to drain into the surrounding chest cavity. This procedure is not a treatment for atrial fibrillation.
Choice D rationale
Synchronized electrical cardioversion is a procedure where a controlled electric shock is delivered to the heart to restore a normal rhythm. It is a common and effective treatment for atrial fibrillation, especially when the condition is causing significant symptoms like palpitations, lightheadedness, and shortness of breath.
A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?
A. Regular diet, no added salt
A regular diet with no added salt may not be sufficient to address the fluid retention associated with acute glomerulonephritis and peripheral edema.
B. Low-protein, low-potassium diet
While a low-protein, low-potassium diet may be considered for certain kidney conditions, it does not specifically address the fluid and sodium management needed in acute glomerulonephritis with edema.
C. Low-carbohydrate, low-protein diet
A low-carbohydrate, low-protein diet is not indicated in this scenario as it does not provide the necessary restrictions on sodium and fluid that are required for a child with edema and oliguria due to acute glomerulonephritis.
D. Low-sodium, fluid-restricted diet
A low-sodium, fluid-restricted diet is most appropriate for a child with acute glomerulonephritis and peripheral edema. This diet helps manage the edema and prevent further fluid overload, which is crucial in the care of this condition.
Full Explanation
Choice A rationale
A regular diet with no added salt may not be sufficient to address the fluid retention associated with acute glomerulonephritis and peripheral edema.
Choice B rationale
While a low-protein, low-potassium diet may be considered for certain kidney conditions, it does not specifically address the fluid and sodium management needed in acute glomerulonephritis with edema.
Choice C rationale
A low-carbohydrate, low-protein diet is not indicated in this scenario as it does not provide the necessary restrictions on sodium and fluid that are required for a child with edema and oliguria due to acute glomerulonephritis.
Choice D rationale
A low-sodium, fluid-restricted diet is most appropriate for a child with acute glomerulonephritis and peripheral edema. This diet helps manage the edema and prevent further fluid overload, which is crucial in the care of this condition.
A nurse is caring for an older adult client who has significant issues with ascites related to end-stage liver disease. Which of the following precautions is most important for the nurse to include in the teaching?
A. "An increased weight in the abdomen can lead to problems with getting comfortable when lying down; therefore, have extra pillows in bed."
While having extra pillows can help with comfort, it does not address the primary safety concern associated with ascites, which is the risk of falls due to altered center of gravity and balance.
B. "Due to the increased weight in the abdomen, it is advised that you do not wear undergarments as they may not fit properly."
The advice about undergarments is not a safety precaution but rather a comfort consideration. It is less critical than ensuring the client's safety while ambulating.
C. "Due to the increased abdominal weight, take your time with walking as your balance might be affected and could cause a fall."
This is the correct choice because it directly addresses a significant safety risk for the client. Ascites can greatly affect balance, increasing the risk of falls, which can lead to serious injury, especially in older adults.
D. "The increased weight in your abdomen will mean that you can no longer exercise due to the strain on your heart."
While exercise is important, this statement is overly restrictive and not accurate. Clients with ascites can often still engage in exercise, albeit modified, to accommodate their condition and under medical supervision.
Full Explanation
Choice A rationale
While having extra pillows can help with comfort, it does not address the primary safety concern associated with ascites, which is the risk of falls due to altered center of gravity and balance.
Choice B rationale
The advice about undergarments is not a safety precaution but rather a comfort consideration. It is less critical than ensuring the client's safety while ambulating.
Choice C rationale
This is the correct choice because it directly addresses a significant safety risk for the client. Ascites can greatly affect balance, increasing the risk of falls, which can lead to serious injury, especially in older adults.
Choice D rationale
While exercise is important, this statement is overly restrictive and not accurate. Clients with ascites can often still engage in exercise, albeit modified, to accommodate their condition and under medical supervision.
