A&C I Heart Failure #2

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

"I plan to slow down if I am tired the day after exercising." Clients who experience chest pain or dyspnea while exercising or experience fatigue the next day are probably advancing the activity too quickly and should slow down.

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided HF. Which of the following manifestations should alert the nurse the client is developing this condition?

Breathlessness Manifestations of left-sided heart failure include crackles or wheezes and breathlessness due to pulmonary congestion.

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the client's vital signs. It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm.

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP) CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure.

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Exercise at least three times per week. The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure.

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

Fatigue The nurse should expect to find the client with fatigue due to muscle weakness with hypokalemia.

A nurse is caring for an older adult client who has left sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy sputum Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

A nurse is assessing a client who has left-sided HF. Which of the following findings should the nurse expect?

Hacking cough A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as a manifestation of which of the following conditions?

Heart Failure Fatigue and tachycardia are early manifestations of heart failure. Other manifestations include dyspnea and weak peripheral pulses.

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Hepatomegaly Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure.

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?

Measure the client's apical pulse. Digoxin decreases the heart rate, so the nurse should count the apical pulse for at least 1 min before administering. The nurse should hold the medication and notify the provider if the client's heart rate is below 60/min or if a change in heart rhythm is detected.

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

Obstructive sleep apnea (OSA) The nurse should include OSA as a risk factor in the development of hypertension. OSA is a condition in which the client's airway becomes blocked by the relaxation of the tongue and muscles of the oropharynx, effectively obstructing the airway. The obstructed airway results in surges in the both the systolic and diastolic pressure during sleep and, in some clients, through the waking hours even when breathing is normal.

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/84 mmHg places him in which of the following categories?

Prehypertension A blood pressure of 124/84 mmHg places this client in the prehypertension category. Prehypertension is indicated by a systolic pressure between 120 and 130 mm Hg and a diastolic pressure between 80 and 89 mm Hg.

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

Repeat auscultation after asking the client to breathe deeply and cough. Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

A nurse is carign for a client who has a prescription for digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tab. The client's current vital signs are: BP 144/96, HR 54/min, resp 18/min, and temp 98.6 F. WHich of the following actions should the nurse take?

Withhold the digoxin does for decreased pulse rate. The nurse should withhold the prescribed dose of digoxin as the heart rate is less than 60/min, and notify the provider.