Chapt. 29: Management of Patients with Complications from Heart Disease

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1. The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem?

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Terms in this set (39)

C) Pulmonary edema

2. The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patients risk for heart failure (HF)?

D) The patients age is greater than 65.

3. The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patients medical history, what is a potential primary cause of the patients
heart failure?

C) Atherosclerosis

4. Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?

B) Monitor for hypotension

5. The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patients diagnosis?

B) Distended neck veins

6. The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms?

A) Confusion and bradycardia

7. A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela?

A) Stroke

8. The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum?

B) Potassium level

9. The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first?

D) Gently shake and shout, Are you OK?

11. A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient?

A) In a high Fowlers position

12. The nurse has entered a patients room and found the patient unresponsive and not breathing. What is the nurses next appropriate action?D) Activate the Emergency Response System (ERS).13. The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting?C) Monitor her weight daily14. The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure?C) Bibasilar fine crackles15. A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurses nutritional teaching plan has been effective?B) I will have a baked potato with broiled chicken for dinner.16. The nurses comprehensive assessment of a patient who has HF includes evaluation of the patients hepatojugular reflux. What action should the nurse perform during this assessment?B) Press the right upper abdomen.17. The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock?B) The patient admitted following an MI19. The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurses rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? A) Pulseless electrical activity (PEA) B) Ventricular fibrillation C) Ventricular tachycardia D) AsystoleAns: D Feedback: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.18. When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?D) A systolic blood pressure that is lower during inhalation20. The nurse is reviewing a newly admitted patients electronic health record, which notes a history of orthopnea? What nursing action is most clearly indicated?D) Avoid positioning the patient supine.21. The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patients care?A) Improve functional status C) Extend survival. E) Relieve patient symptoms.22. A patient with HF has met with his primary care provider and begun treatment with an angiotensin- converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment?A) Blood pressure23. The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient?A) A beta-adrenergic blocker24. The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs?C) Combination of hydralazine and isosorbide dinitrate25. A patient with a diagnosis of HF is started on a beta-blocker. What is the nurses priority role during gradual increases in the patients dose? A) Educating the patient that symptom relief may not occur for several weeksA) Educating the patient that symptom relief may not occur for several weeks26. The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF?A) An S3 heart sound27. An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patients most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patients subsequent care, what nursing diagnosis should be identified?D) Risk for falls related to hypotension28. The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patients sensorium and LOC. Why is the assessment of the patients sensorium and LOC important in patients with HF?A) HF ultimately affects oxygen transportation to the brain.29. Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following?A) Perform at least 100 chest compressions per minute.30. The nurse is providing patient education prior to a patients discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist?A) Know how to recognize and prevent orthostatic hypotension.31. The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics?B) Take the diuretic in the morning to avoid interfering with sleep.32. The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with HF. What should the nurse teach this patient about exercise?B) Eventually aim to work up to 30 minutes of exercise each day.33. The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.A) Facilitate the presence of friends and family whenever possible. C) Provide supplemental oxygen, as needed. D) Provide validation of the patients expressions of anxiety.34. The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply.B) Fluid status C) Cardiac rhythm D) Action of medications35. A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurses best action?A) Rapidly assess the patients cardiopulmonary status.36. The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action?C) Stay with the patient.37. A cardiac patients resistance to left ventricular filling has caused blood to back up into the patients circulatory system. What health problem is likely to result?A) Acute pulmonary edema38. A patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patients health history creates a heightened risk of intracardiac thrombi?A) Atrial fibrillation40. The nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical intervention can be performed that may extend the survival of the patient?A) Insertion of an implantable cardioverter defibrillator39. Diagnostic imaging reveals that the quantity of fluid in a clients pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication? C) Cardiac tamponadeC) Cardiac tamponade