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 :

🔷 Clients on a low-sodium diet must be educated that restaurant and processed foods are often high in sodium, even without visibly adding salt.

🔷Assuming food is "safe" because no extra salt is added ignores hidden sodium content in sauces, seasonings, and preparation methods.

🔷This misconception indicates the client needs additional education about hidden sources of sodium, especially when dining out.

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Answer 2

Correct Answers:

Laparoscopic splenectomy

Rationale :

🔹 In immune thrombocytopenic purpura (ITP), the spleen plays a major role in destroying platelets.

🔹When medical therapy is ineffective, a laparoscopic splenectomy is considered to reduce platelet destruction and increase platelet count.

🔹Transfusions are often ineffective as transfused platelets are also destroyed, and neither ADAMTS-13 nor protamine sulfate is appropriate for ITP.

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Answer 3

Correct Answers:

24

Rationale :

🔸 Use formula:

👉(Dose ÷ Conc) × Volume.

✍️To calculate:

Ordered dose: 1,200 units/hr
Concentration: 25,000 units in 500 mL

Rate = (1200 ÷ 25000 ) × 500

👉 = 24 mL/hr

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Answer 4

Correct Answers:

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

Rationale :

🔷 This client has chest pain, elevated troponin (1.20 ng/mL), and ST-elevation on ECG, confirming STEMI (ST-elevation myocardial infarction).

🔷 The gold standard treatment is PCI (percutaneous coronary intervention) within 90 minutes of hospital arrival to restore blood flow and minimize heart damage.

🔷Other options (diuretics, cardioversion, stress test) are not appropriate during acute STEMI.

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Answer 5

Correct Answers:

Large von Willebrand factor molecules from your plasma

Rationale :

🔶In thrombotic thrombocytopenic purpura (TTP), large von Willebrand factor (vWF) multimers contribute to abnormal clotting and platelet consumption.

🔶Plasmapheresis removes these molecules and replaces deficient ADAMTS-13, the enzyme that breaks down vWF.

🔶This treatment helps prevent microvascular thrombosis and organ damage.

🔶The goal is not to remove ADAMTS-13, spleen macrophages, or perform weekly treatments unless specified by lab trends.

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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 :

✍️Clients taking digoxin should be taught to check their apical pulse before each dose.

✍️ If the pulse is less than 60 beats/min, the medication should be withheld, and the healthcare provider must be notified.

✍️ Bradycardia is a common sign of digoxin toxicity, especially in older adults.

✍️ Loss of appetite, nausea, vomiting, and abdominal discomfort are early signs of digoxin toxicity.

✍️ The client must be instructed to report these symptoms immediately, as toxicity can progress to visual disturbances, confusion, and arrhythmias if untreated.

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Answer 7

Correct Answers:

Cardiorenal syndrome

Rationale :

⫸ Cardiorenal syndrome occurs when dysfunction in the heart leads to progressive kidney impairment.

⫸ In this client with long-standing left-sided heart failure, the decreased urine output, elevated serum creatinine, and anemia are indicative of declining renal perfusion, characteristic of cardiorenal syndrome.

⫸ This condition is a complication of chronic heart failure where poor cardiac output fails to maintain adequate kidney filtration, leading to

Fluid retention,
Reduced clearance of waste
Worsening heart strain.

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Answer 8

Correct Answers:

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

Rationale :

🔹 Apixaban (Eliquis) is an oral anticoagulant used in clients with atrial fibrillation to prevent thromboembolic stroke.

🔹 It does not regulate heart rate or convert rhythm but rather reduces the formation of clots in the atria, which can travel to the brain.

🔹 Its use is especially important in clients with persistent or non-valvular atrial fibrillation.

🔹 The client’s statement reflects an understanding of the true purpose of the drug: stroke risk reduction.

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Answer 9

Correct Answers:

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

Rationale :

💠 A sudden weight gain of 3 pounds in 2 days for a client with heart failure is an early sign of fluid retention, not excess caloric intake.

💠The correct response should involve reporting to the provider, as this may indicate worsening heart function or poor response to diuretics.

💠Clients must be taught to track daily weights, monitor symptoms, and recognize when intervention is needed—not simply adjust food intake.

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Answer 10

Correct Answers:

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

Rationale :

💎Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, is prescribed in chronic stable angina and heart failure to reduce afterload, lower blood pressure, and decrease myocardial oxygen demand.

💎It indirectly helps prevent ventricular remodeling and progression to heart failure.

💎 While it doesn’t treat acute angina or cholesterol, it significantly improves long-term cardiovascular outcomes by easing the heart’s workload.

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QLexNursing

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. What 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?