Identify the statement below that is NOT an appropriate objective response

For Medicare Part A, match the following definitions:

The nurse is assessing a client being treated for congestive heart failure. What physical findings would indicate that the client’s condition is not improving?

A client is prescribed lisinopril (Zestril) for treatment of heart failure. What assessment finding should cause the nurse concern following the initial administration of this drug?  

The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensive should the nurse identify?

The nurse is educating a client scheduled for elective surgery. The client currently takes aspirin daily. What education should the nurse provide with regard to this medication?    

In a patient with a nursing problem of immobility, the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as most appropriate nursing intervention to prevent a DVT from occurring?  

A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse suspect?

The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client’s care?

During the admission history, prior to a scheduled surgery,  the client reports to the nurse of taking the usual dose of warfarin (Coumadin) the previous day. What is an appropriate nursing action?