308 Ch. 29: Heart Disease Management

What is the best measure for determining the extent of hypoxia caused by pulmonary edema and for monitoring the effects of therapy?

Arterial blood gas (ABG) analysis

The nurse is teaching a group of clients with heart failure about how to decrease leg edema. What dietary advice will the nurse give to clients with severe heart failure?

Avoid the intake of processed and commercially prepared foods

Orthopnea is a classic sign of

sign of left-sided heart failure

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

Which nursing intervention should the nurse perform when a client with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta-blockers?

withhold the drug and inform the primary health care provider

A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination?

- monitor the client for signs of lethargy or confusion - examine the client's neck for distended veins

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"

The nurse is teaching a client with heart failure about digoxin. What statements by the client indicate the teaching is effective?

"I will watch my urine output to be sure that the medication is not affecting my kidneys." "If I take my digoxin I should have limited episodes of shortness of breath."

What is the typical percentage of ejection fraction (EF) in a healthy heart?

55-65%

Standard care for a client with pulmonary edema admitted to the ICU

BP and pulse measurements every 15-30 minutes

This is a key diagnostic indicator of heart failure

Brain natriuretic peptide (BNP)

What does hypertension have to do with heart failure?

Hypertension causes the heart's chambers to enlarge and weaken

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV

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 4cm 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 what?

Left ventricular function

A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure?

Right-sided heart failure

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?

the development of left-sided heart failure

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound?

a third heart sound (S3)

Before administering a beta blocker, the nurse should monitor what?

apical pulse

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the PRIORITY nursing intervention?

assess oxygen saturation

A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber? a. BP of 125/80 b. HR of 55 bpm c. urine output of 300mL in 8 hours d. atrial fibrillation rhythm

b. HR of 55 bpm

The nurse is providing care for a client with pulmonary edema. Which assessment method should the nurse prioritize to monitor the respiratory status of this individual? a. ABG analysis b. Lung sounds c. Pulse oximetry d. Skin color assessment

a. ABG analysis

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

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 digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity? a. calcium level 7.5 mg/dL b. potassium level 2.8 mEq/L c. sodium level 152 mEq/L d. magnesium level 2.5 mg/dL

b. potassium level 2.8 mEq/L

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? a. pedal edema b. pulmonary congestion c. JVD d. nausea

b. pulmonary congestion

Which is a manifestation of right-sided heart failure? a. increase in forward flow b. systemic venous congestion c. accumulation of blood in lungs d. paroxysmal nocturnal dyspnea

b. systemic venous congestion

When a beta blocker is ordered, at what heart rate should the drug be withheld and a provider notified?

below 60 bpm

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 signs and symptoms of _____________ reflect the circular nature of the pathophysiology of heart failure

cardiogenic shock

What is oliguria

decreased urine output seen in kidney failure and dehydration

Hypokalemia

deficient potassium in the blood <3.5 mEq/L

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 heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?

echocardiogram

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

echocardiogram

Hypermagnesemia

excess of magnesium in extracellular fluid >2.5 mEq/L

Hypercalcemia

excessive calcium in the blood >5.3 mg/dL

The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure?

furosemide

Hypernatremia

high levels of sodium in the blood >145 mEq/L

Hypomagnesemia

insufficient magnesium in extracellular fluid <1.5 mEq/L

The degree of cardiogenic shock is proportional to the extent of

left ventricular dysfunction

The nurse is caring for a client with heart failure who is receiving a diuretic medication. What implementation will help the nurse evaluate the client's response of the medication?

measuring intake and output

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

What is a significant clinical finding related to right-sided heart failure?

pitting edema