Ch 32: Concepts of Care for Patients with Cardiac Problems

A nurse prepares to discharge a client who has heart failure. What questions would the nurse ask to ensure this client's safety prior to discharging home? a. Are your bedroom and bathroom on the first floor? b. What social support do you have at home? c. Will you be able to afford your oxygen therapy? d. What spiritual beliefs may impact your recovery? e. Are you able to accurately weigh yourself at home?

A, B, D, C & E??? To ensure safety upon discharge, the nurse would assess for structural barriers to functional ability, such as stairs. Nurse would assess pt's available social support (family, friends, home health services). Pt beliefs about and ability to adhere to meds and tx including daily weight would also be reviewed. Other q's do not specifically address pt safety upon discharge?

A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (SATA) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria

A, B, E, F Hematocrit of 32.8% is low (should be 42.6) indicating dilutional ratio of RBCs to fluid (too much fluid). Serum sodium low bc hemodilution. Microalbuminuria and proteinuria are present, indicating decerase in renal filtration. These are early warning signs of decreased compliance of heart. K levels normal, creatinine normal.

A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at GREATEST risk for the development of acute pericarditis? (SATA) a. 36 year old woman with systemic lupus erythematosus (SLE) b. 42 year old man recovering from coronary artery bypass graft surgery c. 59 year old woman recovering from a hysterectomy d. 80 year old man with a bacterial infection of the respiratory tract e. 88 year old woman with a stage III sacral ulcer

A, B, D Acute pericarditis most commonly associated with acute exacerbations of systemic connective tissue disease, including SLE; with Dressler syndrome, or inflammation of the cardiac sac after cardiac surgery or a MI; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure injuries do not increase risk.

A nurse collaborates with assistive personnel to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (SATA) a. Reposition the client every 2 hours b. Teach the client to perform deep-breathing exercises c. Accurately record intake and output d. Use the same scale to weigh the client each morning e. Place the client on oxygen if the client becomes short of breath

A, C, D The AP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The AP can also accurately record intake/output, and use same scale to weigh pt each AM before breakfast. APs are not qualified to teach or asses the need for and provide O2 therapy.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? a. Assess for symptoms of left-sided heart failure b. Document this as a normal finding c. Call the primary health care provider immediately d. Transfer the client to the intensive care unit

A. Assess for symptoms of left-sided heart failure The presences of an S3 gallop is an early diastolic filling sound indicative of increasing LV pressure and LV failure. The other actions are not warranted.

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take FIRST? a. Assess the client's respiratory status b. Draw blood to assess the client's serum electrolytes c. Administer intravenous furosemide d. Ask the client about current medications

A. Assess the client's respiratory status Assessment of respiratory and oxygenation status is the most important nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics ad asking about current meds are important but not as important.

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the BEST response by the nurse? a. I can stay if you would like to talk more about this b. You are lucky to have such a devoted daughter c. It is normal to feel as though you are a burden d. Would you like to meet with the chaplain?

A. I can stay if you would to talk more about this Depression can occur in pts with HF, esp older adults. Having pt talk about feelings will help focus on actual problem. Open-ended statements allow pt to respond safely and honestly. Other options minimize pt concerns and do not allow nurse to obtain more information to provide pt centered care.

A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation

A. Standard Precautions Pt w/ infective endocarditis does not pose a threat of transmitting the causative organism. Standard Precautions would be used; others not necessary.

A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? a. Use a soft-bristled toothbrush and avoid flossing b. Avoid large crowds and people who are sick c. Change positions slowly to avoid hypotension d. Check your heart rate before taking the medication

B. Avoid large crowds and people who are sick Heart transplant pts must take immunosuppressant therapy for rest of life. Nurse would teach pt to avoid crowds and sick ppl to reduce risk of becoming ill. Meds do not place pt at risk for bleeding, orthostatic hypotension, or changes in HR. Orthostatic hypotension from the denervated heart is generally only a problem in immediate postop period.

A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? a. Walk until you become short of breath, then walk back home b. Begin walking 200 feet a day three times a week c. Do not lift heavy weights for 6 months d. Eat plenty of protein to build your strength

B. Begin walking 200 feet a day three times a week A pt with HF would be taught to conserve energy and given an exercise plan. PT should begin walking 200-400 feet a day 3x a week. Pt should not walk until becoming SOB bc may not make it back home. Lifting restriction specific to pt after valve replacement. Protein helps build strength, not specific to HF.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the BEST response by the nurse? a. The prosthetic valve places you at greater risk for a heart attack b. Blood clots form more easily in artificial replacement valves c. The vein taken from your leg reduces circulation in the leg d. The surgery left a lot of small clots in your heart and lungs

B. Blood clots form more easily in artificial replacement valves Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of clots. The other responses are inaccurate.

A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

B. Dyspnea on exertion Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other S&S do not relate.

A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases

B. Friction rub at the left lower sternal border PT with pericarditis may present with a pericardial friction rub at left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. Other assessments not related.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for ADDITIONAL teaching? a. I'll be able to carry heavy loads after 6 months of rest b. I will have my teeth cleaned by my dentist in 2 weeks c. I must avoid eating foods high in vitamin K, like spinach d. I must use an electric razor instead of a straight razor to shave

B. I will have my teeth cleaned by my dentist in 2 weeks Pts with defective or repaired valves at high risk for endocarditis. Pt with valve surgery should avoid dental procedures for 6 months bc of risk for endocarditis. When undergoing mitral valve replacement surgery, the pt needs to be on anticoagulant therapy to prevent vegetation forming on the new valve. Pts on anticoagulant therapy would be instructed on bleeding precautions including using an electric razor. If pt is prescribed warfarin, the pt should avoid foods high in vitamin K. Pt recovering from open-heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is MOST important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption b. Instruct the client to ask for assistance when rising from bed c. Collaborate with assistive personnel to bathe the client d. Monitor potassium levels and check for signs of hypokalemia

B. Instruct the client to ask for assistance when rising from bed Hypotension is a side effect of ACE inhibitors such as captopril. Pts with a fluid volume deficit should have their volume replaced or start at a lower dose of the drug to minimize this effect. The nurse would instruct the client to seek assistance before arising from bed to avoid injury from postural hypotension. ACE inhibitors do not need to be taken w/ food. Collab with AP to provide hygiene is not a priority. The pt would be encourage to complete ADLs as independently as possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the pt has renal insufficiency secondary to HF.

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. I sleep with four pillows at night b. My shoes fit really tight lately c. I wake up coughing every night d. I have trouble catching my breath

B. My shoes fit really tight lately Signs of systemic congestion occur with right-sided HF. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided HF symptoms include respiratory symptoms - orthopnea, coughing, and difficulty breathing all could be results.

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. I have been drinking more water than usual b. I am awakened by the need to urinate at night c. I must stop halfway up the stairs to catch my breath d. I have experienced blurred vision on several occasions

C. I must stop halfway up the stairs to catch my breath Pts with left-sided HF report weakness/fatigue while performing ADLs, as well as difficulty breathing, or "catching their breath". This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to HF.

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures b. Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness c. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes d. While your heart is recovering, blood flow is diverted away from the brain, increasing the risk of stroke when you stand up

C. Your 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 BP drops caused by position changes do not function. This allows orthostatic hypotension to persist in postop period. Other statements false.

A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take? a. Initiate oxygen therapy b. Hold the next dose c. Instruct the client to drink water d. Administer PRN acetaminophen

D. Administer PRN acetaminophen The vasodilating fx of nitrates frequently cause pts to have headaches in the initial period of therapy. The nurse would inform the pt about this side effect and offer a mild analgesic, such as acetaminophen. The pt's headache is not related to hypoxia or dehydration so O2 or H2O would not help. The pt needs to take the med as prescribed to prevent angina; the med wouldn't be held.

A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching? a. Avoid taking aspirin or aspirin-containing products b. Increase your intake of foods that are high in potassium c. Hold this medication if your pulse rate is below 80 beats/min d. Do not take this medication within 1 hour of taking an antacid

D. Do not take this medication within 1 hour of taking an antacid GI absorption of digoxin is erratic. Many meds, especially antacids, interfere with its absorption. Pts are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cut off. Potassium and aspirin have no impact on digoxin absorption.

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side fo the neck. Which nonpharmacologic comfort measure would the nurse implement? a. Apply an ice pack to the client's chest b. Provide a neck rub, especially on the left side c. Allow the client to lie in bed with the lights down d. Sit the client up with a pillow to lean forward on

D. Sit the client up with a pillow to lean forward on Pain from acute pericarditis may worsen when pt lays supine. Nurse would position pt in a comfortable position, usually upright and leaning slight forward. An ice pack and neck rub will not relieve pain. Dimming lights will not help

A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? a. Avoid drinking more than 3 quarts (3 L) of liquids each day b. Eat six small meals daily instead of three larger meals c. When you feel short of breath, take an additional diuretic d. Weigh yourself each day while wearing the same amount of clothing

D. Weigh yourself each day while wearing the same amount of clothing Pts with HF are instructed to weight themselves daily to detect worsening HF early and avoid complications. Other signs include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of HF. The pt would be taught to eat a heart healthy diet, balance intake and output to prevent dehydration and overload, and take meds as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (SATA) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue

A, B, C, F Clinical findings of heart transplant reject include: SOB, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, HYPOtension, afib/aflutter, decreased activity tolerance, and decreased EF.

A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at GREATEST risk for the development of left-sided heart failure? a. A 36 year old woman with aortic stenosis b. A 42 year old man with pulmonary hypertension c. A 59 year old woman who smokes cigarettes daily d. A 70 year old man who had a cerebral vascular accident

A. A 36 yer old woman with aortic stenosis Cause of LV failure include mitral or aortic valve disease, CAD, and HTN. Pulmonary HTN and chronic cig smoking are risk factors for RV failure. A CVA does not increase risk of HF.

A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? a. Avoid using salt substitutes b. Take your medication with food c. Avoid using aspirin-containing products d. Check your pulse daily

A. Avoid using salt substitutes ACE inhibitors such as enalapril inhibit excretion of potassium. Hyperkalemia can be a life threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the pt's pulse rate. Aspirin is often prescribed with ACE inhibitors and is not contraindicated.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

B. Atrial fibrillation Afib is a clinical manifestation of mitral valve regurg/stenosis. PVCs and bradycardia are not associated with valvular problems but usually identified in pts with electrolyte imbalances, MI, and sinus node problems. Sinus tach is a manifestation of aortic regurg due to decrease in CO.

A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (SATA) a. Teach the client about energy conservation techniques b. Ensure that the client is prescribed a beta blocker c. Document a discussion about advanced directives d. Confirm that a post-discharge nurse visit had been scheduled e. Consult a social worker for additional resources f. Care transition record transmitted to next level of care within 7 days of discharge

B, C, D, F National quality measures aim to decrease HF readmission by proper prep for discharge. These measures include: 1. beta blocker prescribed for LV dysfunction at discharge; 2. post-discharge follow-up appt scheduled w/in 7 days of discharge w/ documentation of location, date, and time; 3. care transition record transmitted to next level of care w/in 7 days of discharge; 4. documentation of discussion of advance directives/advance care planning with a HCP; 5. documentation of execution of advance directives w/in the medical record; and 6. post-discharge eval of pt for symptom assessment and tx adherence within 72 hours of discharge (by phone, office visit, home visit)

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? a. Would you like to speak with a priest or chaplain? b. I will arrange for a psychiatrist to speak with you c. Do you want to come off the transplant list? d. Would you like more information about advance directives?

D. Would you like more information about advance directives? Pt is verbalizing a real concern/fear about negative outcomes of surgery. This anxiety itself can have negative effects on the outcome because of SNS stimulation. The best action is to allow pt to verbalize concern and work toward positive outcome without making pt feel as though concerns are not valid. Pt needs to feel some control over future. Nurse personally provides care to address the pt's concerns instead of immediately calling for the chaplain or psychiatrist. Nurse would not jump to conclusions and suggest taking pt off transplant list, which is the best tx option.

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (SATA) a. Pulmonary crackles b. Confusion c. Pulmonary hypotension d. Dependent edema e. Cough that worsens at night f. Jugular venous distension

A, B, E Left-sided HF occurs w/ decrease in contractility of heart or increase in afterload. Most signs will be in respiratory - crackles, confusion (decreased O2), and cough. RV HF = pulmonary hypotension, edema, and JVD.

A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (SATA) a. Administering beta blockers b. Administering high-dose furosemide c. Preparing for a cardiac catheterization d. Loading the client on digitalis e. Instructing the client to avoid strenuous exercise f. Teaching the client how to use the CardioMEMS

A, C, E Management of obstructive HCM includes administering negative inotropic agents such as beta-adrenergic blocking agents (carvedilol) and calcium antagonists (verapamil). Vasodilators, diuretics, nitrates, and cardiac glycosides are contraindicated in pts with obstructive HCM. Strenuous exercise is also prohibited. Echo, radionuclide imaging, and angiocardiography during cardiac cath are performed to diagnose different cardiomyopathies. The CardioMEMS device is used with clients who have HF.

After teaching a client with congestive hear failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a CORRECT understanding of the teaching related to nutritional intake. (SATA) a. I'll read the nutritional labels on food items for salt content b. I will drink at least 3 L of water each day c. Using salt in moderation will reduce the workload of my heart d. I will eat oatmeal for breakfast instead of ham and eggs e. Substituting fresh vegetables for canned ones will lower my salt intake f. Salt substitutes are a good way to cut down on sodium in my diet

A, D, E Nutritional therapy for CHF focused on decreasing sodium and water retention to decrease heart workload. Pt taught to read labels, omit table salt and foods high in sodium (ham and canned foods), and limit water intake to a normal 2 L/day. Salt subs typically contain K so although not banned pt would have to have renal function and serum K monitored while using them - safer to avoid

A nurse cares for a client with right-sided HF. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. Weight is the best indication that you are gaining or losing fluid b. Daily weights will help us make sure that you're eating properly c. The hospital requires that all clients be weighed daily d. You need to lose weight to decrease the incidence of heart failure

A. Weight is the best indication that you are gaining or losing fluid Daily weights needed to document fluid retention or loss. 1 L of fluid = 2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other responses do not address the importance of monitoring fluid retention/loss.

A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? a. Do you have trouble breathing or chest pain? b. Are you still able to walk upstairs without fatigue? c. Do you awake with breathlessness during the night? d. Do you have new-onset heaviness in your legs?

B. Are you still able to walk upstairs without fatigue? Pts with hx of HF generally have negative findings, such as SOB and fatigue. Nurse needs to determine whether pt's activity is same or worse, or whether pt identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of HF but don't provide data that can determine extent of HF.