Ch 28

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?"

A client is admitted to the hospital with a diagnosis of heart failure, and the physician orders a BNP level. What results would indicate to the nurse that the client is in moderate heart failure?

780 pg/mL

The nurse is administering captopril (Capoten) to a client with a diagnosis of heart failure. What type of medication does the nurse inform the client is taking?

An angiotension converting enzyme inhibitor (ACE) inhibitor

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

Blood pressure 80/46

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

Class 1 (mild)

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 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 the the NYHA?

Class III (moderate)

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?

Dopamine (Intropin)

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 assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding?

Experiences exertional dyspnea when walking 3 feet; states, "I cannot catch my breath."

A client is scheduled for a multiple gated acquisition (MUGA) scan the following day. What medication should the nurse be sure not to administer the morning of the procedure?

Furosemide (Lasix)

You are caring for a client with suspected right-sided heart failure. what would you know that clients with suspected right-sided heart failure may experience?

Gradual unexplained weight gain

The nurse instructs the client with heart failure to weight themselves at the same time each day using the same scale. When should the client contact the physician?

If the weight gain is more than 2lbs in a 24 hour period.

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

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

The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?

Low-sodium diet

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

A client with heart failure informs the nurse he has not had a bowel movement in 2 days. Why would it be important for the nurse to obtain an order for a stool softener?

Straining causes the Valsalva maneuver, which can cause dangerous effects.

A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?

Ventricular assist device (VAD)

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

Withhold the medication and notify the physician of the heart rate.

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 dysrhythmias, respiratory arrest, cardiac arrest

the nurse is caring for a client with heart failure. which 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 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.

The nurse is caring for a client with right-sided heart failure who has ascites and hepatomegaly. What interventions can the nurse first provide to ensure the client has adequate nutritional intake?

offer small, frequent feedings

you are working in a long-term care facility with a group of older adults with cardiac disorders. why would it be important for you to closely monitor an older adult receiving digitalis preparations for cardiac disorders?

older adults are at increased risk for toxicity

A client is taking furosemide (Lasix) for the treatment of heart failure. What food should the nurse suggest that is rich in potassium?

peanut butter

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

potassium level of 3.1

a client with sever mitral valve insufficiency has been admitted to your unit. the client has heart failure and has developed pulmonary edema. what would be the best course of treatment for this client?

surgery

a client diagnosed with heart failure has been admitted to the ICU prior to invasive treatment. what treatment could be considered curative for this client?

surgical ventricular restoration

what disease processes contribute to chronic heart failure? select all that apply

tachydysrhythmias, valvular disease, renal failure

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 his rings have become tight and are difficult to remove.

the client has myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough wit 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 nurse documents pitting edema in the bilateral lower extremities of the client. what does this documentation mean?

there is excess fluid volume in the interstitial space in areas affected by gravity

the student nurse is caring for a client with heart failure. diuretics have been ordered. what method might be used with debilitated patient to help the nurse evaluate the clients response to diuretics?

using urinary catheter