EAQ #3

A client with a history of heart failure and afib reports a nine pound (4 kg) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain? a. fluid retention b. urinary retention c. renal insufficiency d. abdominal distension

a

a client with heart failure has anxiety. which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? a. increases the cardiac workload b. interferes with usual respirations c. produces an elevation in temperature d. decreases the amount of oxygen used

a

an 85 year old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time? a. monitor for cardiovascular irregularities b. inquire about changes in bowel patterns c. assess for leg muscle twitching or weakness d. assess for signs and symptoms of dehydration

a

6 hours after a femopopliteal bypass graft, the client's blood pressure becomes severely elevated. What is the primary reason the nurse notifies the surgeon? A. the increased BP can cause the graft to occlude B. the hypervolemia needs to be corrected immediately C. the clients cardiovascular status can precipitate a brain attack D. the clients intraarterial pressure may compromise the graft's viability

D

The nurse is assessing a client with the diagnosis of left ventricular failure. Which assessment finding does the nurse expect to identify a. crushing chest pain b. dyspnea on exertion c. jugular vein distension d. extension peripheral edema

B

a client has surgery to replace prolapsed mitral valve. What should the nurse teach the client? A. the signs and symptoms of pericarditis B. The signs and symptoms of heart failure C. that cardiac surgery will have to be done eventually for the other valves D. That cardiac surgery will have to be done every 6 months to replace the valve

B

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect a cardiac tamponade? select all that apply a. hypertension b. pulsus paradoxus c. muffles heart sounds d. jugular vein distension e. increased urine output

b, c, d

An older client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? select all that apply a. taking an aspirin a day b. occasional cocaine use c. reduced hemoglobin level d. african- american heritage e. increased high-density lipoprotein (HDL)

b, d

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? a. my ankles are swollen b. i am tired at the end of the day c. when i eat a large meal, i feel bloated d. i have trouble breathing when i walk rapidly

d

What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? a. encourage frequent coughing b. elevate the client's lower extremities c. prepare for modified postural drainage d. place the client in the orthopneic position

d

An older adult client is diagnosed with left-sided congestive heart failure. Which assessment should the nurse expect to find? a. dyspnea b. crackles c. hacking cough d. peripheral edema e. jugular edema

A, B, C

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right- sided heart failure? select all a. dependent edema b. swollen hands and fingers c. collapsed neck veins d. right upper quadrant discomfort e. oliguria

A, B, D

A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when a performing an admission history and physical? a. edema of the feet and ankles b. reddened and painful areas on the calves c. pain when exercising and thickening of the toenails d. ulcers around the ankles and reports of a dull ache in the legs

C

A client with synchronous pacemaker inserted. The nurse observed spiked on the monitor at a regular rate that are not followed by myocardial activity. What conclusion should the nurse make about the pacemaker based on this data? a. loss of battery power b. functioning as expected c. failure to stimulate the heart d. ignoring the clients heartbeat

c

a nurse is preparing medications. which clients health problem motivates the nurse to question a prescription for a beta blocker? a. coronary artery disease b. essential hypertension c. acute heart failure d. sinus tachycardia

c

The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply a. weight loss b. extreme fatigue c. coughing at night d. excessive urination e. difficulty breathing

b, c, e

A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse acts whether the client has been taking any medications, the client replies "I took the blood pressure pills the healthcare provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse? a. You must be quite frightened about having a high blood pressure b. I'm glad to hear you have felt well enough to stop the medication c. It is important to take your medications daily to achieve optimal results d. you will need to document daily whether you took your medications or not

c

A client with heart disease has been reading on the internet about the anatomy and physiology of the heart and tells the nurse: I'm so confused. The nurse reinforces the pattern of circulation in the body. Which client statement indicated a correct understanding? A."Blood enters the heart through the ductus arteriosus, flows into the left side of the heart, and exits via the aorta into the systemic circulation." B."Blood enters the heart from the inferior vena cava; it then flows through the left atrium into the left ventricle, then into the lungs, and back into the aorta." C."Blood enters the heart from the aorta, flows into the right atrium and right ventricle, through the lungs, then into the left atrium and left ventricle, and finally exits through the superior vena cava." D."Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta."

d

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? a. stridor b. crackles c. wheezes d. friction rubs

b

Following a major abdominal surgery, a client has a nasogastric tube attached to continuous low suction. The nurse caring for the client postop monitors the client for what signs of hypokalemia? Select all that apply a. irritability b. dysarrythmias c. muscle weakness d. abdominal cramp e. acidosis

B, C

A client is admitted to the hospital with the diagnosis of MI. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply a. weight loss b. unusual fatigue c. dependent edema d. noturnal dyspnea e. increased urinary output

B, C, D

it is determined that a client with heart block will require implantation of a permanent pacemaker to assist heart function. In explaining the pacemaker to the client, what does the nurse say it is necessary for? a. stimulating a normal heartbeat b. shocking the AV node to contract c. slowing the heart to a more normal rate d. synchronizing the action of the heart valves

a

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening of heart failure? a. i am unable to run a mile now b. i wake up at night SOB c. my wife says i snore very loudly d. my shoes seem larger lately

b

A client is admitted to the hospital with afib. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history a. cystitis as an adult b. pleurisy as an adult c. childhood strep throat d. childhood german measles

c

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? a. to prevent dyspnea b. to prevent cyanosis c. to increase oxygen concentration to heart cells d. to increase oxygen tension in the circulating blood

c

The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition a. loss of cellular constituents in blood b. rapid osmosis from tissue spaces to cells c. increased pressure within the circulatory system d. rapid diffusion of solutes and solvents into plasma

c

how can the nurse best describe heart failure to a client a. a cardiac condition caused by inadequate circulating blood volume b. an acute state in which the pulmonary circulation pressure decreasing c. an inability of the heart to pump in proportion to metabolic needs d. a chronic state in which the systolic blood pressure drops below 90 mm Hg

c

A 75 year old client with a history of hypertension has arrived fo a routine annual health screening. The nurse obtains a sitting blood pressure in the client's left arm of 160/100 mm Hg. What action should the nurse take? A. advise the client to restrict fluid and Na intake, then begin to develop a teaching plan for the client B. inform the primary heathcare provider immediately of the client's BP reading C. record the findings, recognizing that the results is expected for an older adult with a history of hypertension D. evaluate the client for symptoms related to extreme hypertension

d

A client hospitalized for heart failure is receiving digoxin and will continue taking the drug after discharge. What should be included in the plan of care for the next few days? a. monitering vital signs and encouraging a vigorous aerobic exercise program b. providing written material on the adverse effects on the medication c. contacting social services for a home health nursing consultation d. teaching the client how to count the pulse

d

A nurse is caring for a patient with hypertension. Which assessment finding most significantly indicated that a client is hypertensive? a. tachycardia b. extended korotoff sounds c. sustained systolic pressure ranging from 110 to 120 mm Hg d. diastolic blood pressure that remains higher than 90 mm Hg

d

The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicated a clinical manifestation that is related to heart failure? a. i see spots before my eyes b. i am tired at the end of the day c. i feel bloated when i eat a large meal d. i have trouble breathing when i climb a flight of stairs

d

when an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? a. interview he client for a health history b. assess the client's heart and lung sounds c. monitor the client's pulse and temperature d. obtain the client's blood specimen for electrolytes

b

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a MI. Which goal is priority during the acute phase of recovery? a. promote pain relief b. increase activity tolerance c. prevent cardiac dysrhythmias d. maintain K and Na intake

A

A client with a history of heart failure on daily weights has a 2 pound (0.9 kg) weight gain and pitting edema in lower extremities bilaterally. What action should the nurse take next? a. check the record to ascertain the code status b. encourage increased intake of favorite drink c. perform a head-to-toe assessment, including vital signs d. continue to monitor daily weights and edema and document findings

c

The nurse provides discharge teaching to a client who has received prescriptions for digoxin, furosemide, and a 2 gram sodium diet. Which statement from the client indicated that further teaching is needed? a. i must check my pulse every day b. i can gradually increase my exercise as long as I take rest periods c. I should call my healthcare provider if i have difficulty breathing when I am lying flat d. I can use a little table salt on my food as long as i do not use it when cooking my food

d

while assessing the skin of a client, the nurse notices edema at the dorsum of the foot and ankle. Which pre-disposing condition does the nurse anticipate in the client? a. neurotrauma b. hypothyroidism c. hyperthyroidism d. congestive heart failure

d

What clinical indicators is the nurse omst likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply a. edema b. vertigo c. polyuria d. ascites e. palpitations

A, D

A nurse is caring for a client with right- sided heart failure. Which assessment findings are key features of right- sided heart failure? select all that apply A. collapsed neck veins B. distended abdomen C. dependent edema D. urinating at night E. cool extremities

B, C, D

a client with an inferior myocardial infarction has a heart rate of 120 BPM. which goal achievements are priority? a. increase left ventricular filling and improve cardiac output b. decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias c. decrease the workload on the heart and promote maximum coronary artery filling d. increase venous return to the right atrium and increase pulmonary arterial blood flow

c

A client who is suspected of having had a silent myocardial infarction has an ACG prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "why was this test prescribed?" Which is the best reply by the nurse? a. this test will detect your heart sounds b. this test will reflect any heart damage c. this procedure helps us change your heart's rhythm this ECG will tell us how much stress your heart can tolerate

b

A client with a history of hypertension develops pedal edema and hepatomegaly. Which condition does the nurse determine the client is experiencing? a. left ventricular failure b. right ventricular failure c. restrictive pulmonary disease d. obstructive pulmonary disease

b

The nurse is caring for a client with the diagnosis of right ventricular failure? Which condition unrelated to cardiac disease is the major cause of right ventricular failure? a. renal disease b. hypovolemic shock c. severe systemic infection d. chronic obstructive pulmonary disease

d