NUR 2211 Medical Surgical Nursing Chapter 15: Nursing Management: Patients With Complications From Heart Disease

Before discharge, which instruction should a nurse give to a client receiving digoxin?

"Call the physician if your heart rate is above 90 beats/minute."

A nurse is performing chest compressions on a 60-year-old client in cardiac arrest. To which depth would the nurse compress the chest?

2 inches (5 cm)

All of the following are clinical signs and symptoms of left-sided heart failure except for:

A central venous pressure reading greater than 8 mm Hg.

Which is a characteristic of right-sided heart failure?

Jugular vein distention

Which is a manifestation of right-sided heart failure?

Systemic venous congestion

Frequently, what is the earliest symptom of left-sided heart failure?

dyspnea on exertion

A nurse suspects that a client has digoxin toxicity. The nurse should assess for:

vision changes.

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.

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 sleep on three pillows each night."

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

30%

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?

Administer the third sublingual nitroglycerin tablet.

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?

Asystole

A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure?

B-type natriuretic peptide (BNP)

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?

Call for a chest x-ray.

A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next?

Check the client's potassium level.

A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?

Class I (Mild)

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 central venous pressure (CVP)

Which medication reverses digitalis toxicity?

Digoxin immune FAB

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

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 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.

Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion.

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?

Excess pericardial fluid compresses the heart and prevents adequate diastolic filling.

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 45 degrees and lower arms supported by pillows

The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with ordinary physical activity. Under what classification does the nurse understand this patient would be categorized?

II

Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?

Increased pulmonary artery diastolic pressure

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, compressing the heart.

Which feature is the hallmark of systolic heart failure?

Low ejection fraction (EF)

A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)?

Myocardial ischemia

The nurse is caring for a client with severe compensated heart failure. What human brain natriuretic peptide (BNP) medication may be used in a critical care unit with hemodynamic monitoring?

Natrecor

The nurse is working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for the nurse to closely monitor an older adult receiving digitalis preparations for cardiac disorders?

Older adults are at increased risk for toxicity.

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?

Spironolactone

The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home?

"I'm having trouble going up the steps during the day."

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 left-sided heart failure

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."

The nurse instructs a client with heart failure on restricting sodium in the diet. Which client statement indicates that teaching was effective?

"Lemon juice and herbs can be used to replace salt when cooking."

The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding?

The woman may be experiencing an exacerbation of right-sided HF.

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?

Valsartan (Diovan)

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Weighing the client daily at the same time each day

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.

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.

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)?

decrease in renal perfusion

The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy?

decreased left ventricular workload

A nurse is assessing a client with heart failure. What breath sound is commonly auscultated in clients with heart failure?

fine crackles.

The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed?

heart transplant

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?

nausea and vomiting

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective?

peripheral edema

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

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?

Arterial blood gases

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure?

Atrial fibrillation

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?

BP and pulse measurements every 15 to 30 minutes

A client is brought to the emergency department via rescue squad with suspicion of cardiogenic pulmonary edema. What complication should the nurse monitor for? Select all that apply.

Cardiac arrhythmias Respiratory arrest Cardiac arrest

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

Dizziness

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Echocardiogram

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:

Ejection fraction (EF)

The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?

Elevate the head of the bed.

The nurse visits the home of a client with heart failure. Which assessment finding indicates to the nurse that the client's tolerance to activity is deteriorating?

Fatigue after walking to answer the door

The pathophysiology of pericardial effusion is associated with all of the following except:

Increased venous return.

The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What would be an important instruction for the nurse to give a client who is to undergo a MUGA scan?

Lie very still at intermittent times during the test.

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

The nurse is providing discharge teaching to a patient diagnosed with heart failure. What should the nurse teach this patient to do to monitor fluid balance?

Monitor weight daily.

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with a health care provider's order that will relieve anxiety and slow respiratory rate?

Morphine sulfate

The nurse is caring for a client with heart failure who has been prescribed digoxin. What laboratory value for the client can precipitate digoxin toxicity?

Potassium 3.0 milliequivalents per liter

The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide?

Potassium level of 3.1

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?

Preload

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

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 Cough

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

Respiratory alkalosis

The nurse recognizes which symptom as a classic sign of cardiogenic shock?

Restlessness and confusion

What is the main difference between Class I and Class II heart failure as defined by the New York Heart Association (NYHA)?

The level of physical activity each allows

The nurse is administering furosemide to a client with heart failure. What best describes the therapeutic action of the medication?

The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels.

The nurse has attended morning report on a busy medical unit. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock?

The patient admitted following a myocardial infarction (MI).

A client with stage IV heart failure has a living will indicating a ventilator may not be used. The client begins experiencing severe dyspnea. What should the nurse who is caring for this client do?

administer oxygen, morphine, and a bronchodilator for client comfort.

The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema?

decreased left ventricular pumping

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?

echocardiogram

The nurse is interviewing a client during an initial visit at a cardiologist's office. What symptom will the nurse expect to find as an early symptom of chronic heart failure?

fatigue

The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity?

potassium level of 2.8 mEq/L

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?

pulmonary crackles

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

pulmonary embolism.

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%

When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by:

A systolic blood pressure that is lower during inhalation.

A nurse has been providing care for an older adult patient who has a number of comorbid medical conditions. The nurse has been performing frequent assessment throughout the morning due to the patient's pallor, decreased level of consciousness, and unstable vital signs. During the nurse's most recent assessment, the patient has lost consciousness and the carotid pulse is not palpable. What is the nurse's priority action?

Activating the hospital's code system

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 clients reports that these symptoms came on suddenly. The nurse knows that these are symptoms of what condition?

Acute pulmonary edema

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?

An increase in the dose of his prescribed diuretic

A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?

Assess for elevated blood urea nitrogen levels.

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing action?

Assess oxygen saturation

The nurse is providing care for a patient newly diagnosed with systolic heart failure (HF). What medications should the nurse anticipate administering?

Beta-blockers

A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?

Blood pressure 80/46 mm Hg

A patient has been admitted to the hospital with exacerbation of heart failure (HF) that has resulted in pulmonary and peripheral edema. The nurse has been carefully monitoring the trajectory of the patient's signs and symptoms of HF. How can the nurse best monitor the patient's fluid balance?

By performing daily weights at the same time each day

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:

Causing vasodilation and decreasing the heart's workload

Which is a cerebrovascular manifestation of heart failure?

Dizziness

Which describes difficulty breathing when a client is lying flat?

Orthopnea

The client with cardiac failure is taught to report which symptom to the health care provider or clinic immediately?

Persistent cough

A client has been diagnosed with heart failure. What is the major nursing outcome for the client?

Reduce the workload on the heart.

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 is going into cardiogenic shock.

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

The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts?

Treat pulseless ventricular tachycardia.

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure?

ascites

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided heart failure?

ascites

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?

echocardiogram

The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion?

inadequate cardiac output

The critical care nurse is caring for a client with cardiogenic shock. What is the premise for inserting an intra-aortic balloon pump?

inadequate tissue perfusion

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival?

lisinopril

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?

orthopnea