Nursing Care Exam 2

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

BP measurements every 15-30 minutes

The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? a. nocturia b. dizziness c. ascites d. tachycardia

dizziness

Which is a cerebrovascular manifestation of heart failure? a. nocturia b. dizziness c. tachycardia d. ascites

dizziness

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 (p. 822)

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

A client in the hospital informs the nurse he "feels like his heart is racing and can't catch his breath." What does the nurse understand occurs as a result of a tachydysrhythmia?

it reduces ventricular ejection volume

which feature is the hallmark of systolic heart failure? a. basilar crackles b. low ejection fraction (EF) c. pulmonary congestion d. limited activities of daily living (ADLs)

low ejection fraction (EF)

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 BP frequently

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? a. furosemide b. dopamine c. nitroglycerin d. morphine sulfate

morphine sulfate

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

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what action should the nurse perform?

place the client in high Fowler's position (p. 834)

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? a. dry mucous membranes b. hypertension c. pulmonary crackles d. high urine output

pulmonary crackles

As recommended follow-up for a client initially diagnosed with prehypertension, the client should get his or her blood pressure rechecked within which time frame?

recheck in 1 hour (p. 896)

The nurse is discussing cardiac terms with a client who was doing some reading on the Internet. What is the correct response for the nurse when the client asks what affects stroke volume?

stroke volume is affected by temperature and heart rate

The nurse is seeing a client for the first time and has just checked the client's blood pressure. The nurse would consider the client prehypertensive if:

systolic BP is between 120 and 139 mm Hg

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 (p. 832)

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? a. listening to breath sounds b. end-tidal CO2 c. arterial blood gases d. pulse oximetry

arterial blood gases

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure? a. supraventricular tachycardia b. first-degree heart block c. sinus tachycardia d. atrial fibrillaton

atrial fibrillation

The nurse is administering medications on a medical-surgical unit. A client is ordered to receive 40 mg oral nadolol for the treatment of hypertension. Before administering the medication, the nurse should

check the client's heart rate (p. 891)

A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have?

essential (primary)

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?

"Limiting my salt intake to 2 grams per day will improve my blood pressure."

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

30%

A nurse is discussing with a nursing student how to accurately measure blood pressure. What statement by the student indicates an understanding of the education?

a cuff that is too small will give a false high BP

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 nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will decrease preload?

administration of a vasodilating drug (as ordered by a health care provider)

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) (p. 836)

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 function

The nurse is providing care to a client with cardiogenic shock requring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy? a. decreased left ventricular workload b. decreased right ventricular workload c. decreased renal perfusion d. decreased peripheral perfusion to the extremities

decreased left ventricular workload

A patient with long-standing hypertension is admitted to the hospital with hypertensive urgency. The physician orders a chest x-ray, which reveals an enlarged heart. What diagnostic test does the nurse anticipate preparing the patient for to determine left ventricular enlargement?

echocardiography

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? a. sodium 128 me per liter b. potassium 3.0 me per liter c. potassium 5.6 me per liter d. sodium 155 me per liter

potassium 3.0 me per liter

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

preload (p. 677)

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.) a. cough b. ascites c. jugular vein distention d. dyspnea e. pulmonary crackles

pulmonary crackles, dyspnea, and cough

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 patient is flying overseas for 1 week for business and packed antihypertensive medications in a suitcase. After arriving at the intended destination, the patient found that the luggage had been stolen. If the patient cannot take the medication, what condition becomes a concern?

rebound HTN

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. What are risk factors for cardiovascular problems in clients with hypertension? Select all that apply

smoking, DM, and physical inactivity (p. 887)