211 Exam 4
The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information?
"Are you only able to breathe when you are sitting upright?"
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?
"I sleep on three pillows each night."
A patient has missed 2 doses of digitalis. What laboratory results would indicate to the nurse that the patient is within therapeutic range?
2.0 mg/mL
A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be?
30%
A client has had an echocardiogram to measure ejection fracton. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?
55%
A nurse is caring for a client with a cardiac disorder who is prescribed diuretics. What important factor should the nurse include in this client's teaching plan?
A discussion of the signs and symptoms of electrolyte and water loss.
The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure?
A-fib
The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?
ABGs
A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The nurse knows that these are symptoms of what?
Acute pulmonary edema
A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action?
Administer epinephrine.
The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg?
Administer the third sublingual nitroglycerin tablet.
A 70-year-old man has been living with a diagnosis of heart failure (HF) for several years and has been vigilant about monitoring the trajectory of disease and adhering to his prescribed treatment regimen. The man has scheduled an appointment with his primary care provider because he has noted a weight gain of 6 pounds over the past week. The nurse should anticipate that this patient may benefit from which of the following treatment measures?
An increase in the dose of his prescribed diuretic
The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause increased preload. Which response by the student indicates understanding?
Application of antiembolytic stockings
Which measurement should a nurse use to monitor the respiratory status of a client with pulmonary edema?
Arterial blood gas (ABG) analysis
A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?
Assess for elevated blood urea nitrogen levels.
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
BP and pulse measurements every 15 to 30 minutes
A health care provider in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?
Blood pressure 80/46 mm Hg
A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?
Call for Chest x-ray
A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next?
Check the client's potassium level.
The nurse is caring for a client in the hospital with chronic heart failure that has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, he becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?
Class III (Moderate)
A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.)
Cough. Dyspnea. Pulmonary Crackles.
The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition?
Crackles are audible on chest auscultation.
A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved?
Decrease in central venous pressure (CVP)
Which medication reverses digitalis toxicity?
Digoxin immune FAB
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?
Dizziness
Which is a cerebrovascular manifestation of heart failure?
Dizziness
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
Dyspnea on exertion
The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?
Elevate the head of the bed.
A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination?
Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion.
A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence?
Excess pericardial fluid compresses the heart and prevents adequate diastolic filling.
A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload?
Head of the bed elevated 45 degrees and lower arms supported by pillows
The nurse is preparing to administer hydralazine and isosorbide dinitrate. When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse?
Hold the medication and call the health care provider.
The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity. Under what classification does the nurse understand this patient would be categorized?
II
Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?
IV
Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?
Increased pulmonary artery diastolic pressure
The pathophysiology of pericardial effusion is associated with all of the following except:
Increased venous return.
A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client?
Intubation and mechanical ventilation
A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?
JVD is noted 4 cm above the sternal angle.
The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?
Left ventricular function
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?
Left-sided HF
The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What would be an important instruction for the nurse to give a client who is to undergo a MUGA scan?
Lie very still at intermittent times during the test.
Which feature is the hallmark of systolic heart failure?
Low ejection fraction (EF)
Which is the hallmark of heart failure?
Low ejection fraction (EF)
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?
Low-sodium diet
Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?
Monitor BP frequently
The nurse is providing discharge teaching to a patient diagnosed with heart failure. What should the nurse teach this patient to do to monitor fluid balance?
Monitor weight daily
A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate?
Morphine sulfate
The nurse is caring for a client with heart failure that has developed pulmonary edema. The client has become very anxious. What medication would the nurse expect to be ordered to assist this client's breathing and anxiety?
Morphine sulfate
A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)?
Myocardial ischemia
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?
N/V
The nurse is caring for a client with severe compensated heart failure. What human brain natriuretic peptide (BNP) medication may be used in a critical care unit with hemodynamic monitoring?
Natrecor
The nurse is working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for the nurse to closely monitor an older adult receiving digitalis preparations for cardiac disorders?
Older adults are at increased risk for toxicity.
The client with cardiac failure is taught to report which symptom to the physician or clinic immediately?
Persistent cough
The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure?
Pitting edema
Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?
Preload
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?
Pulmonary congestion
A hospitalized client with heart failure puts on the call light and states, "I've become very short of breath, and I've been coughing up this pink frothy sputum." The nurse immediately suspects which of the following complications?
Pulmonary edema
A client with heart failure reports a sudden change in the ability to perceive colors. The client reports nausea, and assessment reveals an irregular pulse of 39 beats per minute. What is the nurse's best action?
Report the possibility of digitalis toxicity to the care provider promptly
The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?
Resp. Alkalosis
The nurse recognizes which symptom as a classic sign of cardiogenic shock?
Restlessness and confusion
Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?
Spironolactone
Which is a manifestation of right-sided heart failure?
Systemic venous congestion
The nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response?
The autonomic nervous system controls the heart rate.
The nurse is administering furosemide to a client with heart failure. What best describes the therapeutic action of the medication?
The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels.
The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding?
The woman may be experiencing an exacerbation of right-sided HF.
The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?
There is excess fluid volume in the interstitial space in areas affected by gravity.
Which is a classic sign of cardiogenic shock?
Tissue hypoperfusion
A client with a history of heart failure is returning from the operating room after inguinal hernia repair and the nurse assesses a low pulse oximetry reading. What is the most important nursing intervention?
Titrate oxygen therapy.
The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer?
Valsartan (Diovan)
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?
Ventricular assist device (VAD)
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?
Weighing the client daily at the same time each day
A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?
Weight
A client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition?
acute pulmonary edema
The nurse is assessing a client with left-sided heart failure. What assessment finding is expected?
air hunger
The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure?
ascites
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:
canned peas. (avoid high salt content foods)
A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)?
decrease in renal perfusion
The nurse is providing care to a client with cardiogenic shock requring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy?
decreased left ventricular workload
A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess?
diuretics
The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse tritrate to improve blood flow to vital organs?
dopamine
A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?
echocardiogram
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
echocardiogram
The nurse is interviewing a client during an initial visit at a cardiologist's office. What symptom will the nurse expect to find as an early symptom of chronic heart failure?
fatigue
A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber?
heart rate of 55 beats per minute
The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed?
heart transplant
The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion?
inadequate cardiac output
The critical care nurse is caring for a client with cardiogenic shock. What is the premise for inserting an intra-aortic balloon pump?
inadequate tissue perfusion
The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival?
lisinopril
A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?
mask
A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis?
orthopnea
When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating
orthopnea
A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective?
peripheral edema
A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what action should the nurse perform?
place the client in high Fowler's position
A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." What additional assessment information would be important for the CSU nurse to obtain?
pulmonary crackles
A nurse suspects that a client has digoxin toxicity. The nurse should assess for:
vision changes.
A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?
visual disturbances.