NUR240 Ch.32 Care for Cardiac Patients

A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the clients heart failure?

"Are you still able to walk upstairs without fatigue?"

A nurse is preparing discharge teaching to a recovering heart transplant. Which statement should the nurse include?

"Avoid large crowds and people who are sick." (Transplant patients must take immunosuppressant therapy for the rest of their lives. Avoiding large crowds and sick people reduce the risk of becoming ill)

A nurse cares for an older adult with heart failure. The client states, "I don't want to be a burden to my daughter, but I can't do this alone. Maybe I should die." What is the best response?

"I can stay with you if you'd like to talk about this more."

What alerts the nurse to the possibility of left-sided failure in a patient at the outpatient clinic?

"I must stop halfway up the stairs to catch my breath." (Client with left-sided heart failure report weakness/fatigue while performing normal activities of daily living.)

After teaching a client with CHF, the nurse assesses the client's understanding. What statements show correct understanding?

"I'll read nutritional labels on food items for salt content." "I will eat oatmeal for breakfast instead of ham and eggs." "Substituting fresh vegetables for canned ones will lower my salt intake." (Focus on dec sodium intake and water retention to dec workload of the heart)

What statement by a client in the cardiac unit alerts the nurse to possible right-sided heart failure?

"My shoes fit really tightly lately." (Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops.)

A client with end-stage heart failure awaiting a transplant appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How should you respond?

"Would you like information about advance directives?"

The patient with a new heart transplant asks why it is important to change positions slowly. How should the nurse respond?

"You're new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." (Bc new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period.)

Which clients on cardiac unit are at greatest risk for development of acute pericarditis?

36-yr-old woman with systemic lupus erythematous (SLE) 42 yr-old-man recovering from coronary artery bypass graft surgery 80 yr-old-man w/bacterial infection of respiratory tract.

Which client on the cardiac unit would be at greatest risk for development of left-sided heart failure?

A 36-yr-old woman with aortic stenosis. (Causes of left ventricular failure include MV or AV disease, CAD, & hypertension.)

A nurse assesses a client after administering the first dose of nitrate. The client reports a headache. What action would the nurse take?

Administer PRN acetaminophen.

While assessing a patient on the cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next?

Assess for symptoms of left-sided heart failure. (The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure.)

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first?

Assess the client's respiratory status. (ABC)

A nurse assesses a client who has MV regurgitation. For which cardiac dysrhythmia would the nurse assess?

Atrial fibrillation. (Manifiestation of MV regurg and stenosis.)

What should the nurse teach the client who is prescribed enalapril?

Avoid using salt substitutes. (ACE inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt subs are composed of potassium chloride.)

A nurse teaches a client with heart failure about energy conservation. What should the nurse include in her teaching?

Begin walking 200 ft a day three times a week.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client wants to know why they will need to take anticoagulants for the rest of their life? What's the best response?

Blood clots form more easily in an artificial replacement valve. (Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and infiltrate the formation of clots.)

A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this patient's teaching?

Do not take this medication within one hour of taking an antacid. (Gastrointestinal absorption of digoxin is erratic. )

A nurse assesses a client with MV stenosis. What clinical sign/symptom would alert the nurse to the possibility that stenosis has progressed?

Dypsnea on exertion. (Dyspnea on exertion develops as the mitral valvular orifice arrows and pressure in the lungs increases.)

Based on national quality measures, which actions would the nurse complete prior to discharging a patient with heart failure?

Ensure the client is on a beta blocker. Document a discussion about advanced directives. Confirm that a postdischarge nurse visit has been scheduled, Care transition record transmitted to next level of care within 7 days of discharge. (document discussion and/or execution of advanced directive within medical record.)

A nurse assesses a client with pericarditis. Which finding would the nurse expect to find?

Friction rub at the left lower sternal border. (They may present with pericardial friction rub at the left lower sternal border. The sound is the result of friction from inflamed pericardial layers when they rub together.

A nurse evaluates lab results for a client with heart failure. Which results would the nurse expect?

Hematocrit 32.8% Serum sodium 130 mEq/L Proteinuria Microalbuminuria (hematocrit should be 42.6, so it's low, indicating a dilutional ratio of RBCs to fluid. SSodium is low bc of hemodilution. Proteinuria and Micro are present, indicating a decrease in renal filtration. Early warning signs of decreased compliance of heart.)

What statement by a client being discharged home after mitral valve replacement surgery indicates a need for further teaching?

I will have my teeth cleaned by my dentist in 2 weeks. (Clients with defective/repaired valves are at high risk for endocarditis. They should avoid dental procedures for 6 months bc of risk for endocarditis.

A nurse assesses a client with left-sided heart failure. Which clinical manifestations would the nurse assess?

Pulmonary crackles, Confusion, Cough that worsens at night. (Left-sided failure occurs with a decrease in contractility of the heart or an increase in after load. Most of the signs are noted in the respiratory system.)

Which instructions would the nurse give to the AP caring for a patient with congestive heart failure?

Reposition the client every 2 hours. Accurately record intake and output. Use the same scale to weigh the client each morning.

A client with acute pericarditis reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?

Sit the client up with a pillow to lean forward on. Pain from pericarditis worsens when the client lays supine.

A nurse cares for a client with infective endocarditis. Which infection control precautions should be used?

Standard Precautions (no threat of transmitting organism.)

What would the nurse include in the discharge teaching of a client with a history of heart failure?

Weigh yourself daily while wearing the same amount of clothing. (Daily weight detects worsening heart failure early, and thus avoids complications.)

A client with right-sided heart failure asks the nurse, "Why do I need to weigh myself everyday?" How should the nurse respond?

Weight is the best indication that you are gaining or losing fluid. (Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 lbs. Weight changes are the most reliable indicator of fluid loss or gain.)