Honan-Chapter 15: Nursing Management: Patients With Complications From Heart Disease
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%
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.
The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure? Atrial fibrillation First-degree heart block Supraventricular tachycardia Sinus tachycardia
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.
Which medication reverses digitalis toxicity? Ibuprofen Warfarin Amlodipine Digoxin immune FAB
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.
Signs of cardiogenic shock include all of the following except: Respiratory alkalosis. Hypertension Tachypnea Tachycardia
Hypertension Explanation: Cardiogenic shock is associated with tissue hypoperfusion; therefore, the blood pressure would be low, not high. Tachycardia and tachypnea are compensatory mechanisms that the body uses to try to regain homeostasis.
Which feature is the hallmark of systolic heart failure? Low ejection fraction (EF) Pulmonary congestion Limited activities of daily living (ADLs) Basilar crackles
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.
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 Nitroglycerin Dopamine Morphine sulfate
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.
Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole? Afterload Preload Ejection fraction Stroke volume
Preload Explanation: Preload is 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 nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis? increased appetite bibasilar rales cleared with coughing orthopnea resting bradycardia
orthopnea Explanation: Decreased left ventricular function would be characterized by orthopnea, dyspnea, anorexia, bibasilar rales not cleared with coughing, and resting tachycardia.
All of the following are clinical signs and symptoms of left-sided heart failure except for: Decreased amount of blood pumped into the aorta. Increased pulmonary venous pressure. A central venous pressure reading greater than 8 mm Hg. Increased fluid in the alveoli.
A central venous pressure reading greater than 8 mm Hg. Explanation: A normal central venous pressure (CVP) reading is 2 to 8 mm Hg. When right-sided heart, not left-sided failure occurs, the CVP reading is greater than 8 mm Hg, indicating hypervolemia or excessive fluid circulating in the body.
Which nursing intervention should the nurse perform when a client with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta-blockers? Observe for symptoms of pulmonary edema. Continue the drug and document in the client's chart. Withhold the drug and inform the primary health care provider. Check for signs of toxicity.
Withhold the drug and inform the primary health care provider. Explanation: Before administering a beta-blocker, the nurse should monitor the client's apical pulse. If the heart rate is less than 60 bpm, the nurse should withhold the drug and inform the primary health care provider.
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
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 hypoxemia.
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
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.
The diagnosis of heart failure is usually confirmed by which of the following? Chest x-ray Echocardiogram Electrocardiogram (12-lead) Ventriculogram
Echocardiogram Explanation: Although the chest X-ray can indicate cardiomegaly and the ECG can indicate a left ventricular abnormality, it is the echocardiogram that is diagnostic. This test measures ejection fraction (EF) which, if greater than 40% and accompanied with signs and symptoms of heart failure, indicates diastolic dysfunction and impaired ventricular relaxation.
The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer? Digoxin (Lanoxin) Valsartan (Diovan) Metolazone (Zaroxolyn) Carvedilol (Coreg)
Valsartan (Diovan) Explanation: Valsartan (Diovan) is the only angiotensin receptor blocker listed. Digitalis/digoxin (Lanoxin) is a cardiac glycoside. Metolazone (Zaroxolyn) is a thiazide diuretic. Carvedilol (Coreg) is a beta-adrenergic blocking agent (beta-blocker).
A client has had an echocardiogram to measure ejection fraction. 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%
55% Explanation: Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.
A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The nurse knows that these are symptoms of what? Acute pulmonary edema Progressive heart failure Pulmonary hypertension Cardiogenic shock
Acute pulmonary edema Explanation: Clients with acute pulmonary edema exhibit sudden dyspnea, wheezing, orthopnea, restlessness, cough (often productive of pink, frothy sputum), cyanosis, tachycardia, and severe apprehension. These symptoms do not indicate progressive heart failure, pulmonary hypertension, or cardiogenic shock.
A 70-year-old man has been living with a diagnosis of heart failure (HF) for several years and has been vigilant about monitoring the trajectory of disease and adhering to his prescribed treatment regimen. The man has scheduled an appointment with his primary care provider because he has noted a weight gain of 6 pounds over the past week. The nurse should anticipate that this patient may benefit from which of the following treatment measures? A further reduction in his dietary sodium intake An increase in the dose of his prescribed diuretic A decrease in his daily activity level Thoracentesis
An increase in the dose of his prescribed diuretic Explanation: If a patient with HF experiences a significant change in weight (i.e., 2- to 3-lb increase in a day or 5-lb increase in a week), the patient is instructed to notify his or her provider or to adjust the medications (e.g., increase the diuretic dose) per provider's directions. Thoracentesis is not relevant, and decreased activity may exacerbate the patient's condition. Decreased sodium intake may be of some benefit, but diuretics will have a greater effect.
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? Tachycardia Ascites Nocturia Dizziness
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.
Which is a potassium-sparing diuretic used in the treatment of heart failure? Spironolactone Bumetanide Chlorothiazide Ethacrynic acid
Spironolactone Explanation: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide diuretic. Bumetanide and ethacrynic acid are loop diuretics.
The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information? "Are you only able to breathe when you are sitting upright?" "How far can you walk without becoming short of breath?" "Are you coughing up blood at night?" "Are you urinating excessively at night?"
"Are you only able to breathe when you are sitting upright?" Explanation: To determine if a client is having orthopnea, the nurse needs to ask about the inability to breathe unless sitting upright. Determining how far the client can walk without becoming short of breath would indicate exertional dyspnea. Coughing up blood would indicate hemoptysis. Urinating excessively at night can be indicative of different factors such as taking a diuretic late in the evening causing the client to urinate often at night. This question would be vague.
A patient has been newly diagnosed with heart failure (HF) and has come to the meet with the nurse at the clinic for health education. What lifestyle recommendation should the nurse provide to this patient when discussing dietary modifications? "It's in your best interests to avoid excessive fluids and sodium in your diet." "Try to replace as many of the complex carbohydrates in your diet with simple sugars." "I'll teach you some good sources of potassium, which you should try to eat regularly." "Many people with HF find that small, frequent meals allow them to manage their diet effectively."
"It's in your best interests to avoid excessive fluids and sodium in your diet." Explanation: Lifestyle recommendations for the management of HF include restriction of dietary sodium; avoidance of excessive fluid intake, alcohol, and smoking; weight reduction when indicated; and regular exercise. It is unnecessary to increase potassium intake, replace complex carbohydrates, or eat frequent, smaller meals.
The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg? Hold any further treatment until the client's blood pressure increases. Notify the health care provider of the chest pain. Administer the third sublingual nitroglycerin tablet. Wait ten minutes after the second tablet to assess pain.
Administer the third sublingual nitroglycerin tablet. Explanation: The nurse will need to administer the third sublingual nitroglycerin tablet. Nitroglycerin is given as three doses for chest pain as the client's blood pressure can tolerate it. The health care provider will be notified after three tablets. The nurse should not hold any further treatment if the client has chest pain. The dosing of nitroglycerin is a five-minute wait.
The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. When the nurse assesses the patient, the patient is found to be experiencing cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? Pulseless electrical activity (PEA) Ventricular fibrillation Ventricular tachycardia Asystole
Asystole Explanation: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absence of a heart rhythm.
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? Intubation of the airway BP and pulse measurements every 15 to 30 minutes Insertion of a central venous catheter Hourly administration of a fluid bolus
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 recognizes that which laboratory test is a key diagnostic indicator of heart failure? Blood urea nitrogen (BUN) Creatinine Brain natriuretic peptide (BNP) Complete blood count (CBC)
Brain natriuretic peptide (BNP) Explanation: BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.
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.
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.
A nurse has performed an assessment of a patient and subsequently administered the patient's scheduled dose of ramipril, an angiotensin-converting enzyme (ACE) inhibitor prescribed for the treatment of the patient's longstanding heart failure (HF). The nurse understands that this drug will aid in the treatment of the patient's disease by: Reducing the patient's overall oxygen demand Reducing preload through the excretion of fluid and sodium Increasing the contractility of the heart and increasing ejection fraction Causing vasodilation and decreasing the heart's workload
Causing vasodilation and decreasing the heart's workload Explanation: ACE inhibitors alleviate heart failure symptoms by causing vasodilation and decreasing myocardial workload. They do not have a positive inotropic effect and do not reduce oxygen demand. As well, ACE inhibitors do not promote the excretion of fluids and sodium like diuretics do.
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)
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 has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition? Crackles are audible on chest auscultation. The patient's blood pressure (BP) is 144/99. The patient has put out 600 mL of dilute urine over the past 8 hours. Blood glucose testing reveals a glucose level of 158 mg/dL.
Crackles are audible on chest auscultation. Explanation: Patients with HF often exhibit crackles, which are produced by the sudden opening of edematous small airways and alveoli that have adhered together by exudate. These may be heard at the end of inspiration and are not cleared with coughing. A widened pulse pressure, increased BP, and production of dilute urine are not characteristic of HF. Changes in blood glucose levels are not normally symptomatic of HF.
Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Electrocardiogram (ECG) Echocardiogram Serum electrolytes Blood urea nitrogen (BUN)
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.
A 69-year-old man has been experiencing progressive dyspnea and activity intolerance in recent months and is currently undergoing a diagnostic workup for heart failure (HF). During echocardiography, systolic HF could be differentiated from diastolic HF by appraising the patient's: Sinus rhythm Ejection fraction (EF) Stroke volume Left ventricular wall thickness
Ejection fraction (EF) Explanation: An assessment of the EF is performed to assist in determining the type of HF. EF, an indication of the volume of blood ejected with each contraction, is calculated by subtracting the amount of blood at the end of systole from the amount at the end of diastole and calculating the percentage of blood that is ejected. The type of HF that a patient is experiencing cannot be determined solely by assessing heart rate or wall thickness. Stroke volume is a component of ejection fraction.
A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, 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.
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
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? Head of the bed elevated 30 degrees and legs elevated on pillows Head of the bed elevated 45 degrees and lower arms supported by pillows Supine with arms elevated on pillows above the level of the heart Prone with legs elevated on pillows
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 diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client? Intubation and mechanical ventilation Face mask with nonrebreather Oxygen cannula at 6 L/minute Venturi mask at 35%
Intubation and mechanical ventilation Explanation: The client's respiratory status is severely compromised and has developed signs of respiratory failure. When respiratory failure occurs, the client is intubated and oxygen is administered under continuous positive airway pressure or with mechanical ventilation with positive end-expiratory pressure. A face mask, cannula, or Venturi mask will not deliver the concentration or ventilatory support that an endotracheal tube with mechanical ventilation will provide.
A nurse has asked the unit educator what happens when the amount of fluid in the pericardial sac increases. What should the educator tell the nurse? It raises the pressure inside the pericardial sac, causing fluid to leak through. It raises the pressure inside the pericardial sac, compressing the lungs. It raises the pressure inside the pericardial sac, compressing the heart. It raises the pressure inside the pericardial sac, causing it to rupture.
It raises the pressure inside the pericardial sac, compressing the heart. Explanation: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart. This causes elevated pressure in all cardiac chambers, decreased venous return due to atrial compression, and an inability of the ventricles to distend and fill adequately. Excess fluid in the pericardial sac does not cause fluid to leak through, compress the lungs, or cause the sac to rupture.
A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? No JVD is present. JVD is noted at the level of the sternal angle. JVD is noted 2 cm above the sternal angle. JVD is noted 4 cm above the sternal angle.
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 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
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.
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 Encourage the client to ambulate in room Titrate milrinone rate slowly before discontinuing Teach the client about safe home use of the medication
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 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
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 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.) Jugular vein distention Ascites Pulmonary crackles Dyspnea Cough
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.
A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure? Left-sided heart failure Chronic heart failure Acute heart failure Right-sided heart failure
Right-sided heart failure Explanation: Signs and symptoms of Right Ventricular Failure include: Weakness; Ascites; Weight gain; Nausea, vomiting; Dysrhythmias; Elevated central venous pressure; Jugular vein distention. The scenario does not indicate whether the heart failure is chronic or acute. Therefore, options A, B, and C are incorrect.
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema? The client says that he has been urinating less frequently at night. The client says he has been hungry in the evening. The client says his rings have become tight and are difficult to remove. The client says he is short of breath when ambulating.
The client says his rings have become tight and are difficult to remove. Explanation: Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.
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 cor pulmonale
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. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.
A critical care nurse is providing care for a patient who was admitted to the intensive care unit after going into cardiogenic shock while on one of the hospital's medical units. This nurse should plan assessments and interventions in the knowledge that the effects of cardiogenic shock primarily result from: Tissue hypoperfusion Toxic effects of cardiac biomarkers Overcompensation by the autonomic nervous system (ANS) Osmotic changes
Tissue hypoperfusion Explanation: The classic signs of cardiogenic shock are those of tissue hypoperfusion and result from heart failure and the overall shock state rather than changes in osmosis of the ANS. Cardiac biomarkers are not toxic.
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant? Implanted cardioverter-defibrillator (ICD) Pacemaker Intra-aortic balloon pump (IABP) Ventricular assist device (VAD)
Ventricular assist device (VAD) Explanation: VADs may be used for one of three purposes:(1) a bridge to recovery, (2) a bridge to transport, or (2) destination therapy (mechanical circulatory support when there is no option for a heart transplant). An implanted cardioverter-defibrillator or pacemaker is not a bridge to transplant and will only correct the conduction disturbance and not the pumping efficiency. An IABP is a temporary, secondary mechanical circulatory pump to supplement the ineffectual contraction of the left ventricle. The IABP is intended for only a few days
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound? a first heart sound (S1). a third heart sound (S3). a fourth heart sound (S4). a murmur.
a third heart sound (S3). Explanation: An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.
A client with heart failure is prescribed an angiotensin converting enzyme (ACE) inhibitor. When teaching the client about this medication, the nurse would explain that this class of medications are effective because they: cause vasodilation to reduce the heart's workload. lead to a reduction in sodium and water retention. cause an increase in myocardial contraction. result in an increase in the oxygen demand.
cause vasodilation to reduce the heart's workload. Explanation: ACE inhibitors block the conversion of angiotensin I to angiotensin II, a vasoconstrictor that can raise blood pressure. These drugs alleviate HF symptoms by causing vasodilation and decreasing myocardial workload. Positive inotropes increase force of myocardial contraction and also increase workload of heart and oxygen demand. Angiotensin II-receptor blockers block the vasoconstricting effect of the renin-angiotensin system and block aldosterone release, leading to a reduction in sodium and water retention.
A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing decompensated heart failure with pulmonary edema. bilateral pneumonia. acute exacerbation of chronic obstructive pulmonary disease. tuberculosis.
decompensated heart failure with pulmonary edema. Explanation: Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated heart failure with pulmonary edema. These signs can be confused with pneumonia and tuberculosis, however the patient reveals course crackles upon auscultation which is indicative of pulmonary edema. A patient with acute COPD would have diminished lung sounds bilaterally.
The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs? dopamine enalapril furosemide metoprolol
dopamine Explanation: Dopamine, a sympathomimetic drug, is used to treat cardiogenic shock. It increases perfusion pressure to improve myocardial contractility and blood flow through vital organs. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and doesn't have a direct effect on contractility or tissue perfusion. Metoprolol is a beta-adrenergic blocker that slows heart rate and lowers blood pressure, undesirable effects when treating cardiogenic shock.
The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure? furosemide spironolactone mannitol metolazone
furosemide Explanation: Loop diuretics such as furosemide, bumetanide, and torsemide are the preferred first-line diuretics because of their efficacy in patients with and without renal impairment. Spironolactone is a potassium diuretic. Mannitol is an osmotic diuretic not used for heart failure. Metolazone is a potassium diuretic not used for first treatment for heart failure. Diuretics should never be used alone to treat HF because they don't prevent further myocardial damage.
The nurse is caring for a client with heart failure who is receiving a diuretic medication. What implementation will help the nurse evaluate the client's response of the medication? using mechanical ventilation measuring intake and output obtaining cardiac output with a pulmonary catheter asking the client about comfort level
measuring intake and output Explanation: To evaluate response to 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
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. Reference:
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 bradycardia postural hypotension
peripheral edema Explanation: Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective. The individual will also most like experience trachycardia instead of bradycardia if the heart failure is worsening ang not responding to captopril.
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. pulmonary embolism. pneumonia. pulmonary edema.
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 with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity? visual disturbances. taste and smell alterations. dry mouth and urine retention. nocturia and sleep disturbances.
visual disturbances. Explanation: Digoxin toxicity may cause visual disturbances (e.g., flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (e.g., headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (e.g., abnormal heart rate, arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.
A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor? fluid intake and output. urine specific gravity. vital signs. weight.
weight. Explanation: Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.
