Cardiovascular Disorders
A nurse is caring for four clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis? a) A client 4 days postoperative after mitral valve replacement b) A client 1 day post coronary stent placement c) A client with hypertrophic cardiomyopathy d) A client with a history of repaired ventricular septal defect
A. A client 4 days postoperative after mitral valve replacement Having prosthetic cardiac valves places the client at high risk for infective endocarditis. Hypertrophic cardiomyopathy and repaired ventricular septal defects are moderate risks for infective endocarditis. Coronary stent placement isn't a risk factor for infective endocarditis.
A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing which of the following? a) Increased myocardial contractility. b) Dilated coronary arteries. c) Decreased electrical conductivity in the heart. d) Decreased cardiac arrhythmias.
A. Increased myocardial contractility. Digoxin is a cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat arrhythmias and does decrease the electrical conductivity of the myocardium, these are not primary reasons for its use in clients with heart failure and pulmonary edema.
A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client? a) Bed rest, keeping the affected extremity flat b) Bed rest with elevation of the affected extremity c) Bed rest with the affected extremity in the dependent position d) Bed rest with all normal activities as long as there no increased pain on the affected site
B. Bed rest with elevation of the affected extremity Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Other answers are incorrect based on appropriate level of activity needed to assist the diagnosis. Bed rest with normal activity is incorrect because pain is not always experienced with a thrombophlebitis.
A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client? a) The dosage of the dobutamine needs to be increased. b) The client is experiencing an exacerbation of the heart failure. c) The dobutamine may need to be decreased. d) The client is experiencing an allergic reaction to the dobutamine.
C. The dobutamine may need to be decreased Dobutamine is a vasoactive adrenergic that works by increasing myocardial contractility and stroke volume in order to increase the cardiac output in heart failure clients. A serious side effect of adrenergic drugs is the worsening of a preexisting cardiac disorder. Increasing the dosage of the drug will worsen the problem. The client shows not symptoms of allergic reaction or heart failure.
Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet? a) Whole wheat bread. b) Apples. c) Beef tenderloin. d) Tomato juice.
D. Tomato juice. Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.
The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply. a) Soft drinks b) Oatmeal c) Pepperoni pizza d) Bacon e) Apple juice f) Cheese
A. Soft drinks C. Pepperoni pizza D. Bacon F. Cheese Foods high in sodium include cheese, processed meats such as pepperoni and bacon, and soft drinks. Bacon and cheese also have a high fat content.
The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? a) Blood pressure 134/82. b) Ankle brachial index of 0.65. c) Heart rate 57 bpm. d) SpO2 of 94% on room air.
B. Ankle brachial index of 0.65 An Ankle Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history.
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse determines that the client has understood the nurse's instructions when he states he will: a) Wear support hose, using rubber bands to hold the stockings up. b) Lose weight. c) Avoid exercise. d) Perform leg lifts every 4 hours.
B. Lose weight. The client is at risk for development of varicose veins. Therefore, prevention is key in the treatment plan. Maintaining ideal body weight is the goal. In order to achieve this, the client should consume a balanced diet and participate in a regular exercise program. Depending on the individual, leg lifts may or may not be an appropriate activity. Performing leg lifts provides muscular activity and should be done more often than every 4 hours. Wearing support hose is helpful. However, the client should not use rubber bands to hold the stockings up.
Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? a) The client usually walks 3 miles (4.8 kilometers) a day. b) The client will be immobile during and shortly after surgery. c) The client is 5 feet 9 inches (172.5 cm) tall and weighs 128 lb (58 kg). d) The client has been pregnant four times.
B. The client will be immobile during and shortly after surgery. Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don't apply to this client. Exercise isn't a risk factor for deep vein thrombosis.
The nurse is assessing a client with irreversible shock. The nurse should document which of the following? a) Increased alertness. b) Hypertension. c) Circulatory collapse. d) Diuresis.
C. Circulatory collapse. Severe hypoperfusion to all vital organs results in failure of the vital functions and then circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms associated with irreversible shock. The client in irreversible shock will not be alert.
When a client has a troponin level of 0.9 ng/mL, which of the following nursing interventions should be implemented? a) Apply oxygen at 2 L/minute per nasal cannula b) Document the finding as the only action c) Notify the healthcare provider d) Encourage the client to ambulate
C. Notify the healthcare provider Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during a myocardial infarction. The healthcare provider should be immediately notified when the troponin level is > 0.1 ng/mL. The client should not be ambulated at this time. Applying oxygen is appropriate, although the use of a nasal cannula is not recommended.
A visiting nurse is teaching a client with heart failure about taking his medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene? a) Ask the physician if the client can take fewer pills each day. b) Come to the client's house each morning to prepare the daily allotment of medications. c) Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications. d) Ask the client's family to take turns coming to the house at each administration time to assist the client with his medications.
C. Teach a family member to fill a medication compliance aid once per week so the client can independently take his medications. The nurse should intervene by asking a family member to fill a compliance aid each week with the client's weekly supply of medications in the appropriate time slots. Family members can't be expected to come to the client's house four times each day to administer medications. The physician shouldn't change the dosing regimen just for convenience. The home care nurse can't visit the client each morning to prepare the daily medication regimen.
The most common site of aneurysm formation is in the: a) descending aorta, beyond the subclavian arteries. b) ascending aorta, around the aortic arch. c) abdominal aorta, just below the renal arteries. d) aortic arch, around the ascending and descending aorta.
C. abdominal aorta, just below the renal arteries About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries.
A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an: a) antihypertensive. b) antibiotic. c) anticoagulant. d) anticonvulsant.
C. anticoagulant During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. Nurses don't routinely give antibiotics during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics to reduce the risk of infection. An antihypertensive may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn't indicated because this procedure doesn't increase the risk of seizures.
A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include? a) "Client will verbalize the intention to avoid exercise." b) "Client will verbalize the intention to stop smoking." c) "Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours." d) "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol."
B. "Client will verbalize the intention to stop smoking." A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn't subside after three nitroglycerin doses taken 5 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).
A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? Select all that apply. a) Jugular vein distention b) Cough c) Crackles d) Hepatomegaly e) Ascites f) Orthopnea
B. Cough C. Crackles F. Orthopnea Left-sided heart failure produces primarily pulmonary signs and symptoms, such as orthopnea, cough, and crackles. Right-sided heart failure primarily produces systemic signs and symptoms, such as ascites, jugular vein distention, and hepatomegaly.
After evaluating a client for hypertension, a physician orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have? a) Decreased blood pressure with reflex tachycardia b) Increased cardiac output and increased systolic and diastolic blood pressure c) Decreased cardiac output and decreased systolic and diastolic blood pressure d) Decreased peripheral vascular resistance
C. Decreased cardiac output and decreased systolic and diastolic blood pressure As a long-acting, selective beta1-adrenergic blocker, atenolol decreases cardiac output and systolic and diastolic blood pressure; however, like other beta-adrenergic blockers, it increases peripheral vascular resistance at rest and with exercise. Atenolol may cause bradycardia, not tachycardia.
During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route should the nurse use? a) 2 mg I.V. b) 0.6 mg I.M. c) 2 mg I.M. d) 1 mg I.V.
D. 1 mg I.V. To reverse arrhythmias, bradycardia, or sinus arrest, the usual adult dosage of atropine is 0.5 to 1 mg I.V. every 3 to 5 minutes as needed. The drug isn't administered I.M. for the treatment of bradycardia.
A client with heart failure has not slept for the past 3 nights because of dyspnea. Arterial blood gas (ABG) analysis reveals pH, 7.32; PaO2, 79 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 29 mEq/L. What is the priority nursing intervention for this client? a) Establish venous access with an IV (intravenous) line. b) Elevate the head of the bed so it is easier for the client to breathe. c) Ask the client whether he/she has been taking his/her furosemide as ordered. d) Apply oxygen via nasal cannula at 2 L/min.
D. Apply oxygen via nasal cannula at 2 L/min. These ABG values suggest hypoxia (insufficient oxygen in the blood), which indicates impaired gas exchange. Therefore, applying oxygen will be the priority intervention. Establishing venous access is important, but not the priority. The client can be questioned about his/her medications when he/she is more stable. Elevating the head of the bed may assist in respirations, but is not a priority.
What is the most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program? a) Walking increases high-density lipoprotein (HDL) level. b) Walking aids in weight reduction. c) Walking decreases venous congestion. d) Walking reduces stress.
C. Walking decreases venous congestion. Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs, which are all beneficial to a client with peripheral vascular disease. However, these changes do not have as significant an effect on the client's condition as decreasing venous congestion.
The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which of the following electrolyte imbalances? a) Hyponatremia. b) Hypocalcemia. c) Hypermagnesemia. d) Hyperkalemia.
D. Hyperkalemia Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor. Hyperkalemia can be a side effect of ACE inhibitors. Because of this side effect, ACE inhibitors should not be administered with potassium-sparing diuretics.
The nurse is caring for a client admitted for a quadruple coronary artery bypass graft. Which of the following statements by the client indicate that preoperative teaching has not been effective? Select all that apply. a) "I had stopped smoking a month before the surgery; however, I will be able to start again once I have recovered." b) "I know that I will have to perform deep breathing and coughing exercises to prevent complications." c) "I will be relieved to have this surgery over with; I have a very busy schedule at work right now." d) "I understand that I need to change my eating habits and activity levels to keep my heart healthy." e) "I will be on a heart monitor and a respirator to help me breathe."
A. "I had stopped smoking a month before the surgery; however, I will be able to start again once I have recovered." C. "I will be relieved to have this surgery over with; I have a very busy schedule at work right now." Both of these statements indicate that the client believes the surgery will solve the problem and lifestyle changes are not necessary. There is no demonstration of understanding of preoperative teaching. "I know that I will have to perform deep breathing and coughing exercises to prevent complications," "I will be on a heart monitor and a respirator to help me breathe," and "I understand that I need to change my eating habits and activity levels to keep my heart healthy" are all positive statements that indicate a good understanding of the teaching, indicating the client is an active participant and is following guidelines to help in recovery after the surgery and promote heart health.
A nurse notes that the client's PR interval is .17 and the QRS complex is .10. What action should the nurse take next? a) Document the findings. b) Administer the ordered nitroglycerin paste. c) Request a 12-lead electrocardiogram. d) Give 2 liters of oxygen via nasal cannula.
A. Document the findings. These are normal findings. The nurse should document the findings. A 12-lead ECG would be ordered if the client needs further evaluation in the event of an abnormal finding. Administering nitroglycerin is a routine intervention and not related to the measured PR and QRS intervals. Oxygen administration is not indicated in the presence of normal findings.
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following orders from the health care provider should the nurse verify before implementing? a) Metoprolol 5 mg IV push. b) Prepare for a pulmonary artery catheter insertion. c) Call for urine output < 30 mL/hr for 2 consecutive hours. d) Titrate dobutamine to keep systolic BP > 100.
A. Metoprolol 5 mg IV push. Metoprolol is indicated in the treatment of hemodynamically stable patients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.
A nurse is assigned with an ancillary staff member to care for a group of cardiac clients. Which client should the nurse address first? a) The client who suffered an acute myocardial infarction (MI) who is complaining of constipation. b) The client who had a pacemaker inserted yesterday and who is complaining of incisional pain. c) The client who has his call light on. d) The client admitted with unstable angina pectoris who wants to be discharged.
A. The client who suffered an acute myocardial infarction (MI) who is complaining of constipation. The client who suffered an acute MI who is complaining of constipation should be addressed first. If the client strains at stool after an MI, the vagal response may be stimulated, causing bradycardia thereby provoking arrhythmias. After addressing the MI client with constipation, the nurse should promptly address the pain-relief needs of the client who had a pacemaker inserted the previous day. The nurse should delegate answering the call light to the ancillary personnel. She may also delegate some of the discharge preparation, such as packing the client's belongings.
The nurse is discussing medications with a client with hypertension who has a prescription for furosemide daily. The client needs further education when stating which of the following? a) "I need to be sure to also take the potassium supplement that the doctor prescribed along with my furosemide." b) "I know I should not drive after taking my furosemide." c) "I should be careful not to stand up too quickly when taking furosemide." d) "I should take the furosemide in the morning instead of before bed."
B. "I know I should not drive after taking my furosemide." Furosemide is a diuretic often prescribed for clients with hypertension or heart failure; the drug should not affect a client's ability to drive safely. Furosemide may cause orthostatic hypotension, and clients should be instructed to be careful when changing from supine to sitting to standing. Diuretics should be taken in the morning if possible to prevent sleep disturbance due to the need to get up to void. Furosemide is a loop diuretic that is not potassium-sparing; clients should take potassium supplements as prescribed and have their serum potassium levels checked at prescribed intervals.
A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair with the legs in a dependent position. Which of the following goals is the priority? a) Maintain body temperature. b) Decrease venous congestion. c) Maintain normal respirations. d) Prevent injury to lower extremities.
B. Decrease venous congestion. Decreasing venous congestion in the extremities is a desired outcome for clients with heart failure. The nurse should elevate the client's legs above the level of the heart to achieve this goal. The client is not demonstrating difficulty breathing or being cold. The nurse should prevent injury to the swollen extremity; however, this is not the priority.
The plan of care for a client with hypertension taking propranolol hydrochloride should include: a) Measuring partial thromboplastin time weekly to evaluate blood clotting status. b) Instructing the client to notify the physician of irregular or slowed pulse rate. c) Instructing the client to discontinue the drug if nausea occurs. d) Monitoring blood pressure every week and adjusting the medication dose accordingly.
B. Instructing the client to notify the physician of irregular or slowed pulse rate. Propranolol hydrochloride is a beta-adrenergic blocking agent used to treat hypertension. In addition to lowering blood pressure by blocking sympathetic nervous system stimulation, the drug lowers the heart rate. Therefore, the client should be assessed for bradycardia and other arrhythmias. The client needs to be instructed not to discontinue medication because sudden withdrawal of propranolol hydrochloride may cause rebound hypertension. Propranolol dosage is not typically adjusted based on weekly blood pressure readings. Measurement of partial thromboplastin time values is not a factor in treatment of hypertension.
The nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing interventions should the nurse include in the care plan for the next 8 hours? Select all that apply. a) Monitor the vital signs every 4 hours. b) Maintain pressure over the femoral access site. c) Allow the client to sit upright for meals. d) Keep the extremity straight. e) Allow use of the bedside commode. f) Check the dressing and access site for bleeding.
B. Maintain pressure over the femoral access site. D. Keep the extremity straight. F. Check the dressing and access site for bleeding. Pressure should be applied at the access site to control bleeding and promote clot formation. The dressing and access site must be observed frequently for bleeding and hematoma formation. When the femoral access site is used, the head of the bed may not be raised greater than 30 degrees and the affected leg must be kept extended. Therefore, the client may not sit upright for meals or use the bedside commode. Following this procedure, the nurse should monitor vital signs every 15 minutes for the first hour, every 30 minutes for the next 2 hours, and every 4 hours after that.
A client with peripheral vascular disease has poor circulation. The nurse should assess the client for which of the following? Select all that apply. a) Fluid intake. b) Skin temperature. c) Pain in extremity. d) Nail bed color. e) Nausea.
B. Skin temperature. C. Pain in extremity. D. Nail bed color. Maintaining circulation is critical in individuals with peripheral vascular disease. Skin and nail bed color and temperature will reveal the degree to which the extremity is receiving blood flow. Clients with peripheral vascular disease also usually have a certain amount of pain, especially when the oxygen demand becomes greater than oxygen supply, such as with walking or exercising. Fluid intake and reports of nausea are unrelated to peripheral circulation.
A client is receiving cilostazol for peripheral arterial disease, causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following: a) "My toes are turning grayish black in color." b) "I am having fewer aches and pains." c) "I am able to walk further without leg pain." d) "I do not have headaches anymore."
C. "I am able to walk further without leg pain." Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. "Aches and pains" do not specify exactly where the pain is occurring. Headaches may be a side effect of this drug, and the client should report this information to the health care provider. Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body.
A nurse knows that the major clinical use of dobutamine is to: a) treat hypertension. b) prevent sinus bradycardia. c) increase cardiac output. d) treat hypotension.
C. increase cardiac output Dobutamine increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.
A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. What other client presentation increases the likelihood of a cardiovascular disorder? a) Irritability b) Urinary frequency c) Lower substernal abdominal pain d) Clubbing of fingers
D. Clubbing of fingers Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, palpitations, fainting, fatigue, and peripheral edema. Clubbing of fingers indicates chronic hypoxemia, possibly as a result of undiagnosed heart disease. Urinary frequency is a symptom of a UTI or other urinary tract issue. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders.
What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock? a) Cardiac pacemaker b) Defibrillator c) Hypothermia-hyperthermia machine d) Intra-aortic balloon pump
D. Intra-aortic balloon pump Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate. Hypothermia-hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for termination of life-threatening ventricular rhythms.
Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure? a) Increased pulmonary artery diastolic pressure b) Decreased central venous pressure c) Increase in the cardiac index d) Decreased mean pulmonary artery pressure
A. Increased pulmonary artery diastolic pressure Increased pulmonary artery diastolic pressure suggests left-sided heart failure. Central venous pressure increases in heart failure rather than decreases. The cardiac index decreases in heart failure. The mean pulmonary artery pressure increases in heart failure.
When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply. a) Weight loss of 2 lb (0.9 kg) in 1 day. b) Weight gain of 2 lb (0.9 kg) or more in 1 day. c) High intake of sodium for breakfast. d) Becoming increasingly short of breath at rest. e) Having to sleep sitting up in a reclining chair.
B. Weight gain of 2 lb (0.9 kg) or more in 1 day. D. Becoming increasingly short of breath at rest. E. Having to sleep sitting up in a reclining chair. The client stating that he would call the physician with increasing shortness of breath, weight gain over 2 lb (0.9 kg) in 1 day, and having to sleep sitting up, indicates that he has understood the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the physician if he or she had consumed a high-sodium breakfast. Instead the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future.
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: a) Clean the incisional area with an antiseptic. b) Place soiled dressings in a waterproof bag before disposing of them. c) Observe careful hand-washing procedures. d) Use prepackaged sterile dressings to cover the incision.
C. Observe careful hand-washing procedures. Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.
The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to help: a) Excrete excessive fluids accumulated during the night. b) Retard rapid drug absorption. c) Prevent sleep disturbances during the night. d) Prevent electrolyte imbalances.
C. Prevent sleep disturbances during the night. When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.
