evolve
Which nursing diagnoses may be considered for the client with heart failure? (Select all that apply.) A) Excess Fluid Volume related to compromised regulatory mechanism B) Impaired Physical Mobility related to limited cardiovascular endurance C) Impaired Gas Exchange related to ventilation perfusion imbalance D) Potential for Pulmonary Edema E) Risk for Ineffective Tissue Perfusion, renal, related to hypervolemia
A, B, C, D
What are important considerations when administering a human B-type natriuretic peptide (hBNP) such as nesiritide (Natrecor) for acute cardiac failure? (Select all that apply.) A) Carefully monitor blood pressure. B) Carefully monitor respiratory rate. C) Give every 8 hours. D) Keep the client NPO (nothing by mouth). E) Use a separate infusion line.
A, E
The home care nurse is caring for the client recently discharged from the hospital with a congestive heart failure (CHF) exacerbation. Which statement by the client indicates the need for further teaching about the nurse's plan of care? A) ''I may have a cough.'' B) ''I will measure how much I eat and drink.'' C) ''My nurse will ask how many pillows I sleep on at night.'' D) ''I will be assessed for overnight weight gain.''
A-A cough is indicative of CHF
The nurse is educating the client who has undergone a mitral valve replacement for severe regurgitation. Which statement by the client indicates the need for further teaching? A) ''I don't need to take any more medications.'' B) ''I should call my doctor if I get a fever, shortness of breath, or heart palpitations.'' C) ''I may hear my heart 'click'.'' D) ''I should remind my dentist of my valve problem.''
A-Clients who have had mitral valve replacement usually have a complicated drug regimen to follow
The client is admitted to the hospital with shortness of breath and intermittent chest pain. A cardiac catheterization shows inadequate relaxation of the left ventricle during diastole, and the ejection fraction is 48%. Which type of heart failure might this client be experiencing? A) Diastolic heart failure B) High-output failure C) Systolic ventricular dysfunction D) Ventricular failure
A-Diastolic heart failure occurs when the left ventricle is unable to relax adequately during diastole. Inadequate relaxation or ''stiffening'' prevents the ventricle from filling with sufficient blood to ensure an adequate cardiac output. Although the ejection fraction is higher than 40%, the ventricle becomes less compliant over time because more pressure is needed to move the same amount of volume as compared with a healthy heart.
The client with cardiac failure is being discharged. The client's spouse asks the nurse where to get more information on lifestyle and dietary modification. What does the nurse recommend? A) American Heart Association B) American Lung Association C) Hospital dietician D) Physician
A-The American Heart Association is an excellent community resource for pamphlets, books, cookbooks, and videotapes related to HF and heart disease. The organization also provides referrals to various local support groups for clients and their caregivers.
While assessing the newly admitted client with heart failure, which sign or symptom indicates that emergency action is needed? A) Expectorating frothy, pink-tinged sputum B) Shortness of breath C) Increased abdominal girth D) Inability to sleep in the recumbent position, requiring pillows
A-The expectoration of frothy, pink-tinged sputum is an indication of life-threatening pulmonary edema-
The disease management nurse is teaching the client ways to reduce preload. The first intervention talked about is maintaining fluid and sodium restrictions. Which occurrence reported by the client indicates that teaching and implementation was successful? A) Pants that have become loose in the waist B) Removal of wedding ring because of tightness C) Urinating frequently at night D) Pants that have become tight in the waist
A-Weight is the best indicator of fluid retention or loss. This client's weight loss indicates successful compliance with fluid and sodium restrictions
The client who has been admitted for the third time this year for cardiac failure says, ''This isn't worth it anymore. I just want it all to end.'' What is the nurse's best response? A) Calls the family to lift the client's spirits B) Considers further assessment for depression C) Sedates the client D) Tells the client that things will get better
B-This client is at risk for depression because of the diagnosis of heart failure and further assessment should be done
The client, a college athlete who has collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, ''This can't be. I am in great shape. I eat right and exercise.'' What is the nurse's best response? A) ''How does this make you feel?'' B) ''It can be caused by taking performance-enhancing drugs.'' C) ''It can be a genetic trait.'' D) ''Just imagine how bad it would be if you weren't in good shape.''
C-Hypertrophic cardiomyopathy is often transmitted as a single-gene autosomal dominant trait
The client is exhibiting signs of pulmonary edema as a result of congestive heart failure (CHF). Which nursing intervention demonstrates best practice in the care of this client? A) Auscultating the lung sounds anteriorly. B) Placing the client in a semi-Fowler's position if blood pressure is adequate C) Administering high-flow oxygen at 5-6 liters via simple face mask to maintain SpO2 at >90% D) Providing an oral diuretic
C-Increasing tissue perfusion by oxygenation is the priority nursing action for this client-
. The nurse is providing discharge education for the client going home after a hospital admission for heart failure. Which statement by the client indicates a need for further instruction? A) ''I need to drink fewer liquids.'' B) ''I must eat less salt.'' C) ''I need to start jogging every day.'' D) ''I must stop taking Motrin.
C-The client should stay as active as possible, but should not overdo it with daily jogging. -
Harvey is a 76-year-old man being followed up by his nurse practitioner for congestive heart failure (CHF). Which assessment finding does the nurse find in this client that is not a cause for concern? A) Auscultation of crackles B) Pedal edema C) Weight loss of 6 pounds since the last visit D) Eating seven large cups of ice chips daily
C-Weight loss in this client indicates effective diuretic drug therapy. -
The client admitted to the hospital with end-stage heart disease has no written advanced directives. What does the nurse do? A) Calls the hospital ethics department B) Instructs the family to obtain them C) Nothing; it is the client's right to not have them. D) Provides information about them
D-The nurse should provide information to the client about the importance of advance directives.
The older adult client with cardiac failure is being discharged. The client's activity is severely limited and the family does not appear to have the resources to support the client's care. What does the nurse do? A) Calls a long-term care facility B) Contacts a case manager, if available C) Continues the discharge as ordered D) Delays the discharge
B-In this case, contacting a case manager is the best course of action.
Which statement is true of valvular heart disease or disorders? A) Clients with aortic insufficiency may present with symptoms of dyspnea on exertion, atrial fibrillation, and hemoptysis. B) Clients with mitral valve prolapse (MVP) may present with symptoms of atypical pain, palpitations, and atrial tachycardia. C) In clients with aortic regurgitation, the aortic orifice narrows and obstructs left ventricular outflow during systole. D) In mitral stenosis, the valve leaflets fuse and become stiff, and the chordae tendineae lengthen and become weak.
B-Most clients with MVP are asymptomatic. However, some may report chest pain, palpitations, or exercise intolerance. Atypical chest pain is usually described as a sharp pain localized to the left side of the chest
The client had heart transplantation surgery 2 days ago and is experiencing extreme orthostatic hypotension. What does the nurse do? A) Calls the surgeon B) Cautions the client to change positions slowly C) Gives pain medication D) Increases intravenous fluids
B-Orthostatic hypotension is an expected side effect of the surgery because of heart denervation
The nurse is assessing the client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? A) Friction rub auscultated at the left lower sternal border B) Pain aggravated by breathing, coughing, and swallowing C) Splinter hemorrhages D) Thickening of the endocardium
C-Splinter hemorrhages are indicative of infective endocarditis
The client is prescribed digoxin after having open heart surgery and postoperative atrial fibrillation. Which statement by the client demonstrates the need for further teaching about digoxin therapy? A) ''I must keep all my laboratory appointments.'' B) ''I should not take digoxin at the same time as antacids or laxatives.'' C) ''I should notify my doctor if my pulse is less than 60 or more than 100 beats per minute.'' D) ''If I forget to take digoxin one day, I should double up on the dose the next day.''
D-A forgotten dose may be delayed a few hours. However, if it is remembered just on the next day, only the usual daily dose should be taken.
Although the client with cardiac failure is asymptomatic, the nurse suspects noncompliance to the prescribed home therapy. Which laboratory test confirms the nurse's suspicions? A) B-type natriuretic peptide (BNP) B) Electrolytes C) Hemoglobin and hematocrit D) Digoxin level of 0.2 ng/dL
D-A therapeutic digoxin level is 0.5 to 0.8 ng/dL. A level of 0.2 ng/dL indicates the client has not been taking his or her digoxin dose correctly
The nurse is caring for the client with congestive heart failure (CHF) in the coronary care unit (CCU). The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? A) Determines the client's physical limitations B) Encourages alternate rest and activity periods C) Monitors and documents heart rate, rhythm, and pulses D) Positions the client to alleviate dyspnea
D-Positioning the client to alleviate dyspnea will help ease air hunger and anxiety-
The nurse is providing discharge teaching to the client recovering from heart failure. Which statement by the client indicates that the nurse's instruction was effective? A) ''If I am thirsty, that is my body telling me to drink more fluids.'' B) ''If I get swollen ankles, I should take another 'water pill' (diuretic).'' C) ''Swollen ankles are the best indicator of fluid retention.'' D) ''Weight gain is the best indicator of fluid retention.''
D-Weight should be measured and documented the same time every day to assess for fluid retention-
