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Care of Patients With Cardiac Problems NCLEX
Terms in this set (68)
A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect?
a. A decrease in blood pressure and urine output
b. An increase in creatinine and extremity edema
c. An increase in heart rate and respiratory rate
d. A decrease in respirations and oxygen saturation
In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings.
A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change?
a. Increase in stroke volume
b. Decrease in tissue perfusion
c. Increase in oxygen saturation
d. Decrease in arterial vasoconstriction
In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. Stroke volume and oxygen saturation do not increase with a low ejection fraction.
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure?
a. Middle-aged woman with aortic stenosis
b. Middle-aged man with pulmonary hypertension
c. Older woman who smokes cigarettes daily
d. Older man who has had a myocardial infarction
Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.
The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure?
a. "I have been drinking more water than usual."
b. "I have been awakened by the need to urinate at night."
c. "I have to stop halfway up the stairs to catch my breath."
d. "I have experienced blurred vision on several occasions."
Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.
A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client?
a. "Please come into the clinic for an evaluation."
b. "Increase your fluid intake during waking hours."
c. "Use an over-the-counter cough suppressant."
d. "Sleep on two pillows to facilitate postnasal drainage."
The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible.
The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure?
a. "I sleep with four pillows at night."
b. "My shoes fit really tight lately."
c. "I wake up coughing every night."
d. "I have trouble catching my breath."
Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.
The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment?
a. This is a normal finding.
b. The heart is hypertrophied.
c. The left ventricle is contracted.
d. The client has pulsus alternans.
The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left.
The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's best intervention?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the health care provider immediately.
d. Transfer the client to the intensive care unit.
The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.
A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response?
a. "Weight is the best indication that you are gaining or losing fluid."
b. "Daily weights will help us make sure that you're eating properly."
c. "The hospital requires that all inpatients be weighed daily."
d. "You need to lose weight to decrease the incidence of heart failure."
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.
A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action?
a. Place the client in a high Fowler's position.
b. Begin cardiopulmonary resuscitation (CPR).
c. Promote rest and minimize activities.
d. Administer loop diuretics as prescribed.
The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler's position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.
A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action?
a. Place the client in a high Fowler's position.
b. Perform nasotracheal suctioning of the client.
c. Auscultate the client's heart and lung sounds.
d. Place the client on a 1000 mL fluid restriction.
Placing a client in a high Fowler's position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client's heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed.
A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client?
a. "Avoid using salt substitutes."
b. "Take your medication with food."
c. "Avoid using aspirin-containing products."
d. "Check your pulse daily."
Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.
The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client?
a. Administer this medication before meals to aid absorption.
b. Instruct the client to ask for assistance when arising from bed.
c. Give the medication with milk to prevent stomach upset.
d. Monitor the potassium level and check for symptoms of hypokalemia.
Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension.
The client who just started taking isosorbide dinitrate (Isordil) reports a headache. What is the nurse's best action?
a. Titrate oxygen to relieve headache.
b. Hold the next dose of Isordil.
c. Instruct the client to drink water.
d. Administer PRN acetaminophen.
The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen.
The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention?
a. Insert an indwelling urinary catheter.
b. Monitor the client's blood pressure.
c. Place the nitroglycerin under the client's tongue.
d. Monitor the client's serum glucose level.
Intravenous nitroglycerin and morphine will decrease the client's blood pressure, so it is important to monitor closely for hypotension. Intravenous medications are not administered under the tongue. Although the client may need an indwelling urinary catheter to monitor output, it is not the priority. The client's glucose levels should not be affected by these medications.
The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client?
a. "Avoid taking aspirin or aspirin-containing products."
b. "Increase your intake of foods high in potassium."
c. "Hold this medication if your pulse rate is below 80 beats/min."
d. "Do not take this medication within 1 hour of taking an antacid."
Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.
A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse?
c. Pulse of 62 beats/min
d. Potassium of 2.9 mEq/L
Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headache may occur with any medication and is not a serious side effect. Bradycardia is not likely to occur with this medication.
The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity?
a. Decrease in oxygen saturation from 98% to 95%
b. Respiratory rate change from 22 to 28 breaths/min
c. Systolic blood pressure change from 136 to 96 mm Hg
d. Increase in heart rate from 86 to 100 beats/min
A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.
The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication?
c. Sacral edema
d. Irregular heart rate
Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. Dysphagia, sacral edema, and an irregular heart rate are not related to pulmonary edema.
A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure?
a. "Avoid drinking more than 3 quarts of liquids each day."
b. "Eat six small meals daily instead of three larger meals."
c. "When you feel short of breath, take an additional diuretic."
d. "Weigh yourself daily while wearing the same amount of clothing."
Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.
A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention?
a. Assess respiratory status.
b. Monitor electrolyte levels.
c. Administer intravenous fluids.
d. Insert a Foley catheter.
Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously.
The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client's stenosis has progressed?
a. Oxygen saturation of 92%
b. Dyspnea on exertion
c. Muted systolic murmur
d. Upper extremity weakness
Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases.
The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client?
a. Bounding arterial pulse
b. Slow, faint arterial pulse
c. Narrowed pulse pressure
d. Elevated systolic pressure
In aortic stenosis, the client presents with narrowed pulse pressure when blood pressure (BP) is assessed.
A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse's best response?
a. "The prosthetic valve places you at greater risk for a heart attack."
b. "Blood clots form more easily in artificial replacement valves."
c. "The vein taken from your leg reduces circulation in the leg."
d. "The surgery left a lot of small clots in your heart and lungs."
Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots.
The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education?
a. "I will be able to carry heavy loads after 6 months of rest."
b. "I will have my teeth cleaned by the dentist in 2 weeks."
c. "I will avoid eating foods high in vitamin K, like spinach."
d. "I will use an electric razor instead of a straight razor to shave."
Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics.
The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about?
a. Family history of coronary artery disease
b. Recent travel to Third World countries
c. Pet ownership, especially cats with litter boxes
d. History of a systemic infection within the past month
The clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. Assessing for coronary artery disease, recent travel, or pet ownership is not related to endocarditis.
The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use?
a. Standard Precautions
b. Bleeding Precautions
c. Reverse isolation
d. Contact isolation
The client with infective endocarditis does not pose any specific threat of transmitting the causative organism.
A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client?
a. Heart rate that speeds up and slows down
b. Friction rub at the left lower sternal border
c. Presence of a regularly gallop rhythm
d. Coarse crackles in bilateral lung bases
The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not relate
The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include?
a. "Take your digoxin at the same time every day."
b. "You should begin an aerobic exercise program."
c. "You should report episodes of dizziness or fainting."
d. "You may have only two alcoholic drinks daily."
The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM.
The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority?
a. Rapid position changes can create shear and friction forces, which can tear out internal vascular sutures.
b. The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure.
c. The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes.
d. The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.
Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period.
A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client's discharge instructions?
a. "Use a soft-bristled toothbrush and avoid flossing."
b. "Avoid large crowds and people who are sick."
c. "Change positions slowly to avoid hypotension."
d. "Check your heart rate before taking the medication."
These agents cause immune suppression, leaving the client more vulnerable to infection.
A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." What is the nurse's best response?
a. "Would you like to speak with a priest or chaplain?"
b. "I will consult a psychiatrist to speak with you."
c. "Do you want to come off the transplant list?"
d. "Would you like information about advance directives?"
The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future.
The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level?
a. "Do you have trouble breathing or chest pain?"
b. "Are you able to walk upstairs without fatigue?"
c. "Do you awake with breathlessness during the night?"
d. "Do you have new-onset heaviness in your legs?"
Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level.
An older adult client with heart failure states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response?
a. "Would you like to talk about this more?"
b. "You're lucky to have such a devoted daughter."
c. "You must feel as though you are a burden."
d. "Would you like an antidepressant medication?"
Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly.
An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority?
b. Chest x-ray
c. T4 and thyroid-stimulating hormone (TSH)
d. Arterial blood gas
Echocardiography is considered the best tool for the diagnosis of heart failure. A chest x-ray probably will be done, and if the client has dyspnea, an arterial blood gas will be drawn, but the echocardiogram is the priority. T4 and TSH might be ordered to assess for a contributing cause of heart failure.
The nurse is caring for a client with severe heart failure. What is the best position in which to place this client?
a. High Fowler's, pillows under arms
b. Semi-Fowler's, with legs elevated
c. High Fowler's, with legs elevated
d. Semi-Fowler's, on the left side
Placing the client in high Fowler's position, with pillows under the arms, allows for maximum chest expansion.
The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction?
a. "Walk until you become short of breath and then walk back home."
b. "Gather everything you need for a chore before you begin."
c. "Pull rather than push or carry items heavier than 5 pounds."
d. "Take a walk after dinner every day to build up your strength."
Gathering all supplies needed for a chore at one time decreases the amount of energy needed.
A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action?
a. Administer the Vasotec.
b. Recheck the blood pressure.
c. Hold the Vasotec.
d. Notify the health care provider.
The nurse should administer the medication. Generally, the health care provider will maintain the client's blood pressure between 90 and 110 mm Hg.
A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication?
a. Insert a separate IV access.
b. Prepare a test bolus dose.
c. Prepare the piggyback line.
d. Administer furosemide (Lasix) first.
Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin. A test bolus is not needed, nor is Lasix. Because the medication should be given through a separate IV, it is not necessary to prepare a piggyback line.
The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.)
a. Pulmonary crackles
b. Confusion, restlessness
c. Pulmonary hypertension
d. Dependent edema
e. S3/S4 summation gallop
f. Cough worsens at night
ANS: A, B, E, F
Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle.
The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply.)
a. Hematocrit (Hct), 32.8%
b. Serum sodium, 130 mEq/L
c. Serum potassium, 4.0 mEq/L
d. Serum creatinine, 1.0 mg/dL
ANS: A, B, E, F
The hematocrit is low (should be 42.6%), indicating a dilutional ratio of red blood cells (RBCs) to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart.
The nurse prepares to administer digoxin to a client with heart failure and notes the following information:
Pulse: 48 and irregular
Potassium level: 3.2 mEq/L
What action does the nurse take?
a. Give digoxin; reassess the heart rate in 30 minutes.
b. Give the digoxin; document assessment findings in the medical record.
c. Hold the digoxin, and obtain a prescription for an additional dose of furosemide.
d. Hold the digoxin, and obtain a prescription for a potassium supplement.
D: Digoxin causes bradycardia; hypokalemia potentiates digitalis. The nurse seeks to correct this situation through collaboration with the provider.
Digoxin causes bradycardia, so should be held. Digoxin is given to treat heart failure and atrial fibrillation, an irregular heart rate. Regardless of mental status, the drug should be held. Hypokalemia potentiates digitalis toxicity. Lasix decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid excess at this time.
A client with heart failure has furosemide (Lasix). Which finding would concern the nurse with this new prescription?
a. Serum sodium level of 135 mEq/L
b. Serum potassium level of 2.8 mEq/L
c. Serum creatinine of 1.0 mg/dL
d. Serum magnesium level of 1.9 mEq/L
B: Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy.
In monitoring the diagnostic test of a client admitted with heart failure (HF), which finding is consistent with this diagnosis?
a. Serum potassium level of 3.2 mEq/L
b. Ejection fraction of 60%
c. B-type natriuretic peptide (BNP) of 760 ng/dL
d. Chest x-ray report showing right middle lobe consolidation
C: BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL.
Hypokalemia may occur in response to diuretic therapy for heart failure but may also occur with other conditions; it is not specific to heart failure. Consolidation on chest x-ray may indicate pneumonia.
The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure?
a. Ibuprofen (Motrin)
b. Hydrochlorothiazide (HydroDIURIL)
c. NPH Insulin
d. Levothyroxine (Synthroid)
A: Long-term use of NSAIDs, such as ibuprofen (Motrin), causes fluid and sodium retention.
A diuretic may be used in the treatment of heart failure and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause heart failure. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism; it does not cause heart failure.
The client begins therapy with lisinopril (Prinivil, Zestril). What should the nurse consider at the start of therapy with this medication?
a. The client's ability to understand medication teaching
b. The risk for hypotension
c. The potential for bradycardia
d. Liver function tests (LFTs)
B: Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.
Although desirable, understanding of medication teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.
The nurse is caring for a client with heart failure. For which symptoms should the nurse assess? Select all that apply.
a. Chest discomfort or pain
c. Expectorates thick, yellow sputum
d. Sleeps on back without a pillow
e. Shortness of breath with exertion
A, B, E: Decreased tissue perfusion may cause chest pain or discomfort. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Dyspnea results as pulmonary venous congestion ensues.
C - Incorrect: Thick, yellow sputum is indicative of infection; clients with acute heart failure have dry cough and, when severe, pink, frothy sputum.
D - Incorrect: Orthopnea, the inability to lie flat, occurs in clients with heart failure.
The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, pink, frothy sputum, and crackles throughout the lung fields. Which prescription should the nurse carry out first?
d. I & O
C: The client is displaying typical signs of acute pulmonary edema, secondary to fluid-filled alveoli and pulmonary congestion; a diuretic will promote fluid loss.
Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis (DVT) secondary to immobility but will not reduce fluid excess. Although all clients with congestive heart failure (CHF) should have I & O maintained, this is not a priority; removing fluid volume and treating dyspnea are matters of priority.
The nurse caring for a client discusses the importance of restricting sodium in the diet. Which statement made by the client indicates that he needs further teaching?
a. "I should avoid grilling hamburgers."
b. "I must cut out bacon and canned foods."
c. "I shouldn't put the salt shaker on the table anymore."
d. "I should avoid lunch meats but may cook my own turkey."
A: Cutting out beef or hamburgers made at home is not necessary; however, fast food hamburgers are to be avoided owing to higher sodium content.
Bacon and canned foods are high in sodium, which promotes fluid retention; these are to be avoided. This client does not need further teaching. The client should avoid adding salt to food; he does not need further teaching. This client understands that all lunch meats and processed foods are high in sodium and are to be avoided.
The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply.
b. Sinus bradycardia
d. Serum digoxin level of 1.5
B, C, E: Digoxin toxicity may be manifested by bradycardia, fatigue, and/or anorexia.
A - Incorrect: Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity.
D - Incorrect: This represents a therapeutic value that is between 0.8 and 2.0.
The nurse recognizes that which medication when given in heart failure may improve morbidity and mortality?
a. Dobutamine (Dobutrex)
b. Carvedilol (Coreg)
c. Digoxin (Lanoxin)
d. Bumetamide (Bumex)
B: Beta-adrenergic blockers reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; they improve morbidity, mortality, and quality of life.
Dobutamine and digoxin are inotropic agents used in acute heart failure; they do not improve mortality. Bumetamide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.
How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen?
a. Ejection fraction is 25%.
b. Client states that she is able to sleep on one pillow.
c. Client was hospitalized five times last year with pulmonary edema.
d. Client reports that she experiences palpitations.
B: Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers.
An ejection fraction of 25% is well below the normal ejection fraction of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.
Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy?
a. Client ambulates around the nursing unit with a walker.
b. The nurse monitors the client's pulse and blood pressure frequently.
c. The nurse obtains a bedside commode before administering furosemide.
d. The nurse returns the client to bed when he becomes tachycardic.
C: Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.
On the day of admission, the client is experiencing dyspnea, fatigue, and weakness; this activity will increase oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.
Which intervention will best assist the client with acute pulmonary edema in reducing anxiety and dyspnea?
a. Monitor pulse oximetry and cardiac rate and rhythm.
b. Reassure the client that his distress can be relieved with proper intervention.
c. Place the client in high Fowler's position with the legs down.
d. Ask a family member to remain with the client.
C: High Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.
Monitoring of vital signs will detect abnormalities but will not prevent them. Option B may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved. Option D may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.
The nurse is providing discharge teaching to the client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates understanding of the teaching?
a. "I will call the provider if I have a cough lasting 3 or more days."
b. "I will report to the provider weight loss of 2 to 3 pounds in a day."
c. "I will try walking for 1 hour each day."
d. "I should expect occasional chest pain."
A: Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified.
The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.
A client admitted for heart failure has a priority problem of Excess Fluid Volume related to compromised regulatory mechanisms. Which of these assessment data obtained the day after admission is the best indicator that the treatment has been effective?
a. The client has a diuresis of 400 mL in 24 hours.
b. The client's blood pressure is 122/84 mm Hg.
c. The client has an apical pulse of 82 beats/min.
d. The client's weight decreases by 2.5 kg.
D: The best indicator of fluid volume loss is daily weight; because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid.
Option A: This volume of urine represents oliguria, not the needed response of diuresis.
Option B: Although this is a normal finding, alone it is not significant for relief of fluid volume excess.
Option C: Although this is a normal finding, alone it is not significant to determine whether fluid excess is relieved.
When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions?
a. Auscultation of crackles
b. Pedal edema
c. Weight loss of 6 pounds since the last visit
d. Reports sucking on ice chips all day for dry mouth
C: Weight loss in this client indicates effective fluid restriction and diuretic drug therapy.
Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. This indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.
The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action should the nurse take first?
a. Assess the client for peripheral edema.
b. Listen to the client's posterior breath sounds.
c. Notify the physician about the client's weight gain.
d. Remind the client about dietary sodium restrictions.
B: Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds.
Assessment of edema may be delayed while the nurse focuses on breathing and breath sounds. After a full assessment, the nurse should notify the physician. Defer this action until physiologic stability is attained; then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.
Which of these nursing actions should the nurse delegate to a nursing assistant working on the medical unit?
a. Determine the usual alcohol intake for a client with cardiomyopathy.
b. Monitor the pain level for a client with acute pericarditis.
c. Obtain daily weights for several clients with class IV heart failure.
d. Check for peripheral edema in a client with endocarditis.
C: Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.
The role of the professional nurse is to perform assessments; do not delegate this activity.
The client who has been admitted for the third time this year for cardiac failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response?
a. Calls the family to lift the client's spirits
b. Considers further assessment for depression
c. Sedates the client to decrease myocardial oxygen demand
d. Tells the client that things will get better
B: This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done.
Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope and ignores his feelings.
Which priority problems may be considered for the client with heart failure? Select all that apply.
a. Decreased fluid volume related to compromised regulatory mechanism
b. Impaired Physical Mobility related to limited cardiovascular endurance
c. Impaired Gas Exchange related to ventilation-perfusion imbalance
d. Potential for pulmonary edema
e. Risk for Ineffective renal Perfusion related to hypervolemia
B, C, D, E: Owing to intra-alveolar edema and poor cardiac output, the client is fatigued, has limited endurance, and may develop hypoxemia. Owing to limited cardiac reserve, the client is at risk for pulmonary edema. The client with heart failure has poor cardiac output, reduced blood flow to the kidney, and accumulation of pulmonary and peripheral fluid.
Although the client with cardiac failure is asymptomatic, the nurse suspects noncompliance with prescribed home therapy. Which laboratory test confirms the nurse's suspicions?
a. B-type natriuretic peptide (BNP) 90 pg/mL
b. Serum electrolytes
c. Hemoglobin and hematocrit
d. Digoxin level of 0.2 ng/dL
D: A therapeutic digoxin level is 0.8 to 2.0 ng/dL. A level of 0.2 ng/dL indicates that the client has not been taking his digoxin as prescribed.
A BNP test is a cardiac failure diagnostic tool but is not the best indicator of decreased compliance. Electrolytes are not an early indicator of decreased cardiac compliance. Hemoglobin and hematocrit are not early indicators of decreased cardiac compliance.
The nurse is caring for the client with congestive heart failure (CHF) in the coronary care unit (CCU). The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client?
a. Determines the client's physical limitations
b. Encourages alternate rest and activity periods
c. Monitors and documents heart rate, rhythm, and pulses
d. Positions the client to alleviate dyspnea
D: Positioning the client to alleviate dyspnea will help ease air hunger and anxiety.
Determining the client's physical limitations and encouraging alternate rest and activity periods are not priorities in this situation. Monitoring of heart rate, rhythm, and pulses is important but is not the priority for this client.
The nurse is assessing the client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis?
a. Friction rub auscultated at the left lower sternal border
b. Pain aggravated by breathing, coughing, and swallowing
c. Splinter hemorrhages
d. Thickening of the endocardium
C: Splinter hemorrhages are indicative of infective endocarditis.
Friction rub in the left lower sternal border is a sign of chronic constrictive pericarditis. Pain aggravated by breathing, coughing, and swallowing is indicative of signs and symptoms of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.
The client, a college athlete who has collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response?
a. "How does this make you feel?"
b. "This can be caused by taking performance-enhancing drugs."
c. "This may be caused by a genetic trait."
d. "Just imagine how bad it would be if you weren't in good shape."
C: Hypertrophic cardiomyopathy is often transmitted as a single-gene autosomal dominant trait.
After receiving change-of-shift report about these four clients, which client should the nurse assess first?
a. The 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset, frequent premature ventricular complexes
b. The 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94%
c. The 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths
d. The 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, rate 104
A: This client's premature ventricular complexes may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity should be done and the physician notified about the dysrhythmia.
Option B: This client is stable.
Option C: This type of pain is expected in pericarditis.
Option D: Tachycardia is expected in this client because rejection will cause signs of decreased cardiac output, including tachycardia.
Which of these clients is best to assign to an LPN/LVN working on the telemetry unit?
a. A client with heart failure who is receiving dobutamine (Dobutrex)
b. A client with restrictive cardiomyopathy who uses oxygen for exertional dyspnea
c. A client with pericarditis who has a paradoxical pulse and distended jugular veins
d. A client with rheumatic fever who has a new systolic murmur
B: This client, who needs oxygen only with exertion, is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice.
Option A: This client is receiving an intravenous inotropic agent, which requires monitoring by the professional nurse.
Option C: This client is displaying signs of cardiac tamponade and requires immediate life-saving intervention.
Option D: A new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the professional nurse.
When caring for a client who has undergone a partial left ventriculectomy, which of these new-onset clinical manifestations indicates the need for immediate action by the nurse?
a. Chest pain with movement
b. Fatigue after ambulation
c. Muffled heart sounds
d. Bi-basilar fine crackles
C: Muffled heart sounds may be a clinical manifestation of bleeding into the pericardial space; the nurse should assess the client for possible decreased cardiac output and should notify the surgeon.
Surgery will result in pain with mobility; pain should be treated but not until physiologic stability is ensured. This procedure was performed for heart failure; this client has had surgery as well and will need some time to recover his energy. Although the nurse should strive to prevent atelectasis or dependent crackles, this common after chest surgery. This client should be gotten out of bed and shown how to use an incentive spirometer.
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