Ch. 29: Mgmt of Pts w/ Complications from Heart Disease

Which is a characteristic of right-sided heart failure? Jugular vein distention Dyspnea Pulmonary crackles Cough

Correct response: Jugular vein distention Explanation: Jugular vein distention is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.

The client with cardiac failure is taught to report which symptom to the physician or clinic immediately? Increased appetite Persistent cough Weight loss Ability to sleep through the night

Correct response: Persistent cough Explanation: Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite, weight gain, interrupted sleep, unusual shortness of breath, and increased swelling should also be reported immediately.

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? Insertion of a central venous catheter Intubation of the airway BP and pulse measurements every 15 to 30 minutes Hourly administration of a fluid bolus

Correct response: BP and pulse measurements every 15 to 30 minutes Explanation: Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.

The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart? pulmonary arterial pressure MRI nuclear angiography echocardiogram

Correct response: echocardiogram Explanation: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. An MRI, pulmonary arterial pressure, and nuclear angiography do not give diagnostic information about the heart's ejection fraction.

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 don't have the same appetite I used to." "My feet are bigger than normal." "My pants don't fit around my waist." "I sleep on three pillows each night."

Correct response: "I sleep on three pillows each night." Explanation: Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding? "?Can'?t walk without becoming short of breath?" ?"Has paroxysmal nocturnal dyspnea when walking?" ?"Has orthopnea when walking"? ?"Experiences exertional dyspnea when walking 3 feet; states, ?"I cannot catch my breath."?

Correct response: ?"Experiences exertional dyspnea when walking 3 feet; states, ?"I cannot catch my breath."? Explanation: Exertional dyspnea is the effort at breathing when active. Answer A is vague and does not give a more detailed explanation for documentation purposes. Orthopnea is the inability to breathe unless sitting upright, and paroxysmal nocturnal dyspnea is being awakened by breathlessness.

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 anemia. A discussion of the signs and symptoms of electrolyte and water loss. A discussion of the required room temperature conditions in the home environment. A discussion on how to avoid direct sunlight when outdoors.

Correct response: A discussion of the signs and symptoms of electrolyte and water loss. Explanation: Instructions for clients taking diuretics should include a discussion of the signs and symptoms of electrolyte and water loss and the importance of adhering to the prescribed medication schedule. The client need not be informed about the symptoms of anemia or be advised to maintain any particular room temperature or avoid sunlight; use of diuretics does not increase risk for developing photosensitivity or anemia.

A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD? An LVAD only supports a failing left ventricle. It is specifically designed for long-term use. It never needs batteries. It is designed for extremely active patients.

Correct response: An LVAD only supports a failing left ventricle. Explanation: A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered? A chest x-ray An echocardiogram An electrocardiogram A ventriculogram

Correct response: An echocardiogram Explanation: Increasing shortness of breath (dyspnea) and fatigue are common signs of left-sided heart failure (HF). However, some of the physical signs that suggest HF may also occur with other diseases, such as renal failure and chronic obstructive pulmonary disease; therefore, diagnostic testing is essential to confirm a diagnosis of HF. Assessment of ventricular function is an essential part of the initial diagnostic workup. An echocardiogram is usually performed to determine the ejection fraction, identify anatomic features such as structural abnormalities and valve malfunction, and confirm the diagnosis of HF.

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? Administer angiotensin II receptor blockers Administer angiotensin-converting enzyme inhibitors Administer diuretics Assess oxygen saturation

Correct response: Assess oxygen saturation Explanation: Assessment is priority to determine the severity of the exacerbation. It is important to assess the oxygen saturation in a client with heart failure because below-normal oxygen saturation can be life-threatening. Treatment options vary according to the severity of the client's condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve symptoms and reduce the workload on the heart by reducing afterload and preload.

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure? Atrial fibrillation Supraventricular tachycardia Sinus tachycardia First-degree heart block

Correct response: Atrial fibrillation Explanation: Cardiac dysrhythmias such as atrial fibrillation may either cause or result from heart failure; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.

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. Avoid the intake of canned fruit and fruit juices. Encourage increased intake of vegetables with natural sodium. Encourage increased intake of red meat.

Correct response: Avoid the intake of processed and commercially prepared foods. Explanation: Until edema resolves, a client with severe heart failure requires restriction of sodium to 500 to 1,000 mg/day. Therefore, processed and commercially prepared foods are eliminated. Vegetables with natural sodium, for example, beets, carrots, and "greens," should be avoided. Fresh, frozen, and canned fruit and fruit juices are not restricted. Increased intake of red meat should not be encouraged; it should be restricted to 6 oz per day

Which of the following is a key diagnostic laboratory test for heart failure? Complete blood count Blood urea nitrogen B-type natriuretic peptide Leukocyte analysis

Correct response: B-type natriuretic peptide Explanation: Although the other tests are important, the B-type natriuretic peptide (BNP) is important because high levels (>100 pg/mL) indicate abnormal ventricular function or symptomatic heart failure.

A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring? Heart rate of 72 beats/minute Respiratory rate of 20 breaths/minute Blood pressure 80/46 mm Hg Oxygen saturation 94%

Correct response: Blood pressure 80/46 mm Hg Explanation: The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minuteis within normal range as well as the blood pressure and oxygen saturation.

Which of the following is a key diagnostic indicator of heart failure (HF)? Brain natriuretic peptide (BNP) Blood urea nitrogen (BUN) Creatinine Complete blood count (CBC)

Correct response: Brain natriuretic peptide (BNP) Explanation: The BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of HF. A BUN, creatinine, and CBC are included in the initial workup.

On assessment, the nurse knows that a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity would have heart failure classified as Stage: A B C D

Correct response: C Explanation: Once a patient has structural heart disease, he has progressed from stage A to either stage B or stage C. The difference between B and C has to do with the presence of signs and symptoms of heart failure. When dyspnea and fatigue occur with exertion, heart failure is suspected.

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? Observe for mist in the endotracheal tube. Listen for breath sounds over the epigastrium. Call for a chest x-ray. Attach a pulse oximeter probe and obtain values.

Correct response: Call for a chest x-ray. Explanation: A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.

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 I (Mild) Class II (Mild) Class III (Moderate) Class IV (Severe)

Correct response: Class III (Moderate) Explanation: Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class I is ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.

The nurse identifies which symptom as a manifestation of right-sided heart failure (HF)? Reduction in cardiac output Congestion in the peripheral tissues Reduction in forward flow Accumulation of blood in the lungs

Correct response: Congestion in the peripheral tissues Explanation: Right-sided HF, failure of the right ventricle, results in congestion in the peripheral tissues and the viscera and causes systemic venous congestion and a reduction in forward flow. Left-sided HF refers to failure of the left ventricle; it results in pulmonary congestion and causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues.

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 blood pressure Decrease in central venous pressure (CVP) Absence of cough Increase in CVP

Correct response: Decrease in central venous pressure (CVP) Explanation: A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade.

What is the primary underlying disorder of pulmonary edema? Decreased left ventricular pumping Decreased right ventricular elasticity Increased left atrial contractility Increased right atrial resistance

Correct response: Decreased left ventricular pumping Explanation: Pulmonary edema is an acute event that results from heart failure. Myocardial scarring, resulting from ischemia, limits the distensibility of the ventricle, making it vulnerable to demands for increased workload. When the demand on the heart increases, there is resistance to left ventricular filling and blood backs up into the pulmonary circulation. Pulmonary edema quickly develops.

The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? Nocturia Dizziness Ascites Tachycardia

Correct response: Dizziness Explanation: Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion include dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.

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 Hypotension Tachycardia Decreased urinary output

Correct response: Dyspnea on exertion Explanation: Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Electrocardiogram (ECG) Echocardiogram Blood urea nitrogen (BUN) Serum electrolytes

Correct response: Echocardiogram Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Electrocardiogram (ECG) Echocardiogram Serum electrolytes Blood urea nitrogen (BUN)

Correct response: Echocardiogram Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.

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 A pulmonary arteriography A chest radiograph Electrocardiogram

Correct response: Echocardiogram Explanation: The heart?'s ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm corpulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart?s conduction system.

A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply. Monitor the client for signs of lethargy or confusion. Examine the client's neck for distended veins. Examine the client's joints for crepitus. Examine the client's eyes for excess tears.

Correct response: Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion. Explanation: During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion. Excess tears are not part of the checklist.

A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, bradycardia, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence? The pericardial space is eliminated with scar tissue and thickened pericardium. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.

Correct response: Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. Explanation: The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).

The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience? Increased urine output Gradual unexplained weight gain Increased perspiration Sleeping in a chair or recliner

Correct response: Gradual unexplained weight gain Explanation: Clients with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention. Left-sided heart failure produces paroxysmal nocturnal dyspnea, which may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Right-sided heart failure does not cause increased perspiration or increased urine output.

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? Supine with arms elevated on pillows above the level of the heart Head of the bed elevated 45 degrees and lower arms supported by pillows Prone with legs elevated on pillows Head of the bed elevated 30 degrees and legs elevated on pillows

Correct response: Head of the bed elevated 45 degrees and lower arms supported by pillows Explanation: Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the client's weight on the shoulder muscles.

A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure? Hypertension causes the heart's chambers to enlarge and weaken. Hypertension causes the heart's chambers to shrink. Heart failure occurs when blood pressures drops. Hypertension in older males regularly leads to heart failure.

Correct response: Hypertension causes the heart's chambers to enlarge and weaken. Explanation: Hypertension causes the heart's chambers to enlarge and weaken, making it impossible for the ventricles to eject all the blood they receive.

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

Correct response: IV Explanation: Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In class II, ADLs are slightly limited. In class III, ADLs are markedly limited.

Which of the following is the primary cause of pulmonary or peripheral congestion? Ascites Hepatomegaly Inadequate cardiac output Nocturia

Correct response: Inadequate cardiac output Explanation: Pulmonary congestion occurs and tissue perfusion is compromised and diminished when the heart, primarily the left ventricle, cannot pump blood out of the ventricle effectively into the aorta and the systemic circulation.

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 2 cm above the sternal angle. JVD is noted 4 cm above the sternal angle. No JVD is present. JVD is noted at the level of the sternal angle.

Correct response: JVD is noted 4 cm above the sternal angle. Explanation: JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

The nurse identifies which symptom as a characteristic of right-sided heart failure? Pulmonary crackles Cough Jugular vein distention (JVD) Dyspnea

Correct response: Jugular vein distention (JVD) Explanation: JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.

A new client has been admitted with right-sided heart failure. When assessing this client, the nurse knows to look for which finding? Pulmonary congestion Cough Dyspnea Jugular venous distention

Correct response: Jugular venous distention Explanation: When the right ventricle cannot effectively pump blood from the ventricle into the pulmonary artery, the blood backs up into the venous system and causes jugular venous distention and congestion in the peripheral tissues and viscera. All the other choices are symptoms of left-sided heart failure.

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 Right ventricular function Left atrial function Right atrial function

Correct response: Left ventricular function Explanation: The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? Cyanosis of the lips Bilateral crackles Productive cough Leg edema

Correct response: Leg edema Explanation: Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough.

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? Furosemide Morphine sulfate Nitroglycerin Dopamine

Correct response: Morphine sulfate Explanation: Morphine seems to help relieve respiratory symptoms by depressing higher cerebral centers, thus relieving anxiety and slowing respiratory rate. Morphine also promotes muscle relaxation and reduces the work of breathing. Furosemide is a loop diuretic and will decrease fluid accumulation but will not reduce anxiety. Nitroglycerin will promote smooth muscle relaxation in the vessel walls and will relieve pain but not reduce anxiety. Dopamine is an inotrope that will increase the force of ventricular contraction but will not alleviate anxiety.

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? Platelet count Potassium Calcium White blood cell (WBC) count

Correct response: Potassium Explanation: Diuretics, such as furosemide (Lasix), are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin (Lanoxin), and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient? Vasculitis Potassium levels Flexion contractures Enlargement of joints

Correct response: Potassium levels Explanation: A key concern associated with digoxin therapy is digitalis toxicity. Clinical manifestations of toxicity include anorexia, nausea, visual disturbances, confusion, and bradycardia. The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole? Afterload Preload Ejection fraction Stroke volume

Correct response: Preload Explanation: Preload is the the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from a ventricle. The ejection fraction is the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole. Stroke volume is the amount of blood pumped out of the ventricle with each contraction.

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 Pedal edema Nausea Jugular venous distention

Correct response: Pulmonary congestion Explanation: When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.

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 Withhold the client's next scheduled dose of furosemide and report to the care provider Monitor the client's vital signs every 30 minutes Facilitate an ophthalmology referral promptly

Correct response: Report the possibility of digitalis toxicity to the care provider promptly Explanation: This client's presentation is characteristic of digitalis toxicity, which must be promptly reported. This constellation of symptoms is less likely to result from furosemide. Close monitoring is necessary; vital signs every 30 minutes is insufficient. Referrals are not the most time-dependent priority.

The nurse recognizes which symptom as a classic sign of cardiogenic shock? Hyperactive bowel sounds High blood pressure Restlessness and confusion Increased urinary output

Correct response: Restlessness and confusion Explanation: Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)? Spironolactone Bumetanide Chlorothiazide Ethacrynic acid

Correct response: Spironolactone Explanation: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide diuretic is Diuril. Bumetanide and ethacrynic acid are loop diuretics.

Which is a manifestation of right-sided heart failure? Reduction in cardiac output Reduction in forward flow Systemic venous congestion Accumulation of blood in the lungs

Correct response: Systemic venous congestion Explanation: Right-sided heart failure causes systemic venous congestion and a reduction in forward flow. Left-sided heart failure causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues.

The nurse is administering nitroglycerin, which he knows decreases preload as well as afterload. Preload refers to which of the following? The amount of resistance to the ejection of blood from the ventricles The force of the contraction related to the sympathetic nervous system The amount of blood presented to the ventricles just before systole Fluid overload and tissue perfusion status

Correct response: The amount of blood presented to the ventricles just before systole Explanation: Preload is the amount of blood presented to the ventricles just before systole. It increases pressure in the ventricles, which stretches the ventricle wall. Like a piece of elastic, the muscle fibers need to be stretched to produce optimal recoil and forceful ejection of blood. Afterload refers to the amount of resistance to the ejection of blood from the ventricle. To eject blood, the ventricles much overcome the resistance caused by tension in the aorta, systemic vessels, and pulmonary artery.

Assessment of a client on a medical surgical unit finds a regular heart rate of 120 beats per minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 mL over the past hour. What is the reason the nurse anticipates transferring the client to the intensive care unit? The client shows signs of aneurysm rupture. The client is in the early stage of right-sided heart failure. The client is going into cardiogenic shock. The client is experiencing heart failure.

Correct response: The client is going into cardiogenic shock. Explanation: This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.

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 chronic obstructive pulmonary disease (COPD) The development of left-sided heart failure The development of right-sided heart failure The development of corpulmonale

Correct response: The development of left-sided heart failure Explanation: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Corpulmonale is a condition in which the heart is affected secondarily by lung damage.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? Measuring and recording fluid intake and output Checking the client's lungs for crackles during every shift Weighing the client daily at the same time each day Assessing the client's vital signs every 4 hours

Correct response: Weighing the client daily at the same time each day Explanation: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

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. right-sided heart failure. pneumonia. cardiogenic shock.

Correct response: acute pulmonary edema. Explanation: Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.

A client has been diagnosed with congestive heart failure. This client's cardiac function has been compromised since the client suffered a myocardial infarction 3 years ago. Heart failure is classified by: amount of activity restriction the failure imposes. severity of the MI. length of disability post-MI. using the New York Heart Association scale.

Correct response: amount of activity restriction the failure imposes. Explanation: Chronic heart failure is classified based on the amount of activity restriction it imposes. Although organizations that develop the classifications may have varying stages, they are all based on the level of activity restriction.

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)? dehydration increased blood volume ejected from ventricle vasodilation of skin decrease in renal perfusion

Correct response: decrease in renal perfusion Explanation: A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.

The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema? decreased right ventricular elasticity increased left atrial contractility increased right atrial resistance decreased left ventricular pumping

Correct response: decreased left ventricular pumping Explanation: Pulmonary edema is an acute event that results from heart failure. Myocardial scarring, resulting from ischemia, limits the distensibility of the ventricle, making it vulnerable to demands for increased workload. When the demand on the heart increases, there is resistance to left ventricular filling and blood backs up into the pulmonary circulation. Pulmonary edema quickly develops.

A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. Which finding indicates a need for immediate attention? lung congestion nausea temperature blood pressure

Correct response: lung congestion Explanation: Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen or mechanical ventilation is used to support breathing. Inotropic medications, which improve myocardial contractility, are administered to relieve symptoms.

The nurse is caring for a client with heart failure who is receiving torsemide. What implementation will help the nurse evaluate the client's response of the medication? asking the client about comfort level using mechanical ventilation measuring intake and output obtaining cardiac output with a pulmonary catheter

Correct response: measuring intake and output Explanation: To evaluate response to torsemide, which is a diuretic, intake and output are monitored. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. Asking the client about comfort level will not assess urinary output.

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client? Vasculitis nausea and vomiting Flexion contractures Enlargement of joints

Correct response: nausea and vomiting Explanation: Digitalis medications are potent and may cause various toxic effects. The nurse should monitor the client for signs of digitalis toxicity, not just during the initial period of therapy, but throughout care management. The most common signs and symptoms include nausea and vomiting which can lead to dehydration and electrolyte imbalance. Symptoms of toxicity do not include vasculitis, flexion contractures, or enlargement of joints.

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 oliguria S4 ventricular gallop sign decreased O2 saturation levels

Correct response: pitting edema Explanation: The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response. Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a thickened left ventricle, seen with aortic stenosis or hypertension. The decreased oxygen saturation levels are from hypoexemia.

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 perform chest physiotherapy have the client take deep breaths and cough administer oxygen

Correct response: place the client in high Fowler's position Explanation: The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase oxygen content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.

The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity? magnesium level of 2.5 mg/dL calcium level of 7.5 mg/dL sodium level of 152 mEq/L potassium level of 2.8 mEq/L

Correct response: potassium level of 2.8 mEq/L Explanation: Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.

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? hypertension high urine output dry mucous membranes pulmonary crackles

Correct response: pulmonary crackles Explanation: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.

A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be? 65% 30% 5% 55%

Correct response: 30% Explanation: The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure.The normal EF is 55%-65%. An EF of 5% is not life sustaining and an EF of 30% is about half the normal percentage.

Which feature is the hallmark of systolic heart failure? Limited activities of daily living (ADLs) Basilar crackles Low ejection fraction (EF) Pulmonary congestion

Correct response: Low ejection fraction (EF) Explanation: A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.

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 blood pressure frequently Teach the client about safe home use of the medication Encourage the client to ambulate in room Titrate milrinone rate slowly before discontinuing

Correct response: Monitor blood pressure frequently Explanation: Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to clients with severe HF, including those who are waiting for a heart transplant. Because the drug causes vasodilation, the client's blood pressure is monitored before administration because if the client is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and after infusions of milrinone.

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.) Pulmonary crackles Dyspnea Jugular vein distention Ascites Cough

Correct response: Pulmonary crackles Dyspnea Cough Explanation: The clinical manifestations of pulmonary congestion associated with left-sided heart failure include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels, but not ascites or jugular vein distention.

Which is a classic sign of cardiogenic shock? Tissue hypoperfusion Hyperactive bowel sounds High blood pressure Increased urinary output

Correct response: Tissue hypoperfusion Explanation: Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation). Low blood pressure is a classic sign of cardiogenic shock. Hypoactive bowel sounds are classic signs of cardiogenic shock. Decreased urinary output is a classic sign of cardiogenic shock.

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 decreased right ventricular workload decreased peripheral perfusion to the extremities decreased renal perfusion

Correct response: decreased left ventricular workload Explanation: The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The therapeutic effect is decreased left ventricular workload. The IABP does not change right ventricular workload. The IABP increases perfusion to the coronary and perpherial arteries. The renal perfusion is not affected by IABP.

When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating dyspnea upon exertion. paroxysmal nocturnal dyspnea. orthopnea. hyperpnea.

Correct response: orthopnea. Explanation: Clients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler position. Dyspnea upon exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective? skin rash peripheral edema dry cough postural hypotension

Correct response: peripheral edema Explanation: Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

Which medication reverses digitalis toxicity? Ibuprofen Warfarin Amlodipine Digoxin immune FAB

Correct response: Digoxin immune FAB Explanation: Digoxin immune FAB binds with digoxin and makes it unavailable for use. The dosage is based on the digoxin concentration and the client's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.

Which is a cerebrovascular manifestation of heart failure? Ascites Nocturia Tachycardia Dizziness

Correct response: Dizziness Explanation: Cerebrovascular manifestations of heart failure include dizziness, lightheadedness, confusion, restlessness, and anxiety. Tachycardia is a cardiovascular manifestation. Ascites is a gastrointestinal manifestation. Nocturia is a renal manifestation.

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 blood pressure of 125/80 urine output of 300 mL in eight hours atrial fibillation rhythm

Correct response: heart rate of 55 beats per minute Explanation: Digoxin therapy slows conduction through the AV node. A heart rate of 55 is slow and the digoxin therapy may slow the heart rate further. Blood pressure of 125/80 is normal. Urine output of 300 mL is adequate, so the kidneys are functioning. Atrial fibrillation is not a parameter to hold medication.

The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed? implantable cardiac defibrillator (ICD) heart transplant ventricular access device cardiac resynchronization therapy

Correct response: heart transplant Explanation: Heart transplantation involves replacing a person's diseased heart with a donor heart. This is an option for advanced HF patients when all other therapies have failed. A ventricular access device, ICD, and cardiac resynchronization therapy would be tried prior to a heart transplant.

The nurse is asssessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion? nocturia hepatomegaly inadequate cardiac output ascites

Correct response: inadequate cardiac output Explanation: Pulmonary congestion occurs and tissue perfusion is compromised and diminished when the heart, primarily the left ventricle, cannot pump blood out of the ventricle effectively into the aorta and the systemic circulation. Ascites is fluid in the abdomen, not a cause of congestion. Hepatomegaly is an enlarged liver, which does not cause crackling breath sounds. Nocturia, or voiding at night, does not cause crackling breath sounds.

A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of myocardial infarction. pneumonia. pulmonary edema. pulmonary embolism.

Correct response: pulmonary embolism. Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

A client is receiving furosemide, a loop diuretic, to prevent fluid overload. The order is for 50 mg intraveneous now. The pharmacy supplies furosemide 80 mg per 2 mL. How many mL will the nurse give the client? Enter the correct number ONLY. ____mL

Correct response: 1.25 Explanation: (50 mg/80 mg) x 2 mL = 1.25 mL.

A patient has missed 2 doses of digitalis. What laboratory results would indicate to the nurse that the patient is within therapeutic range? 3.2 mg/mL 0.25 mg/mL 2.0 mg/mL 4.0 mg/mL

Correct response: 2.0 mg/mL Explanation: For many years, digitalis was considered an essential agent for the treatment of HF, but with the advent of new medications, it is not prescribed as often. Digoxin increases the force of myocardial contraction and slows conduction through the atrioventricular node. It improves contractility, increasing left ventricular output.

A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be? 5% 30% 55% 65%

Correct response: 30% Explanation: The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure.The normal EF is 55-65%. The5%is not life sustaining and the 30 % is about half the normal percentage.

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% 50% 45% 40%

Correct response: 55% Explanation: Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.