Chapter 32: Care of Patients with Cardiac Problems

A nurse is talking with a client who has class I heart failure and asks about obtaining a ventricular assist device (VAD). Which of the following statement should the nurse make? A. "VADs are only implanted during heart transplantation." B. "A VAD helps to pace the heart." C. "VADs are used when heart failure is not responsive to medications." D. "A VAD is useful for clients who also have a chronic lung issue."

A. A VAD is often placed for clients awaiting heart transplant, to maintain adequate circulation. B. A VAD is a pump that promotes blood circulation throughout the body. C. CORRECT: One use for a VAD is to prolong life for clients who have become unresponsive to heart failure medications. D. Implantation of a VAD is contraindicated for dents who also have a chronic lung issue.

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."

ANS: A Angiotensin-converting enzyme (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 substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the client's pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

The nurse expects which outcome in a client who is taking a beta blocker for mild heart failure? A.Increased orthopnea B.Improved urinary output C.Improved activity tolerance D.Increased myocardial contractility

ANS: C Beta-blocker therapy for mild and moderate heart failure can lead to improvement in symptoms, including improved activity tolerance and less orthopnea.

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.

ANS: A Assessment of respiratory and oxygenation status is the most important nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take precedence over assessing respiratory status.

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

ANS: A Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

A nurse cares for a client with right-sided heart failure. 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."

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 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 or loss.

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 you 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?"

ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the client's concerns and do not allow the nurse to obtain more information to provide client-centered care.

A client with chronic heart failure has been prescribed Ivabradine. Which assessment data requires the nurse to contact the health care provider before administering this medication? A.Hypotension B.Ejection fraction of 29% C.Resting heart rate 80 beats/min D.Patient is currently on a beta blocker

ANS: A Ivabradine is used for HF clients who have an ejection fraction (EF) <30% who are in sinus rhythm with a resting heart rate ≥70 beats/min. This medication is used for clients who are either on the maximally tolerated dose of beta blocker therapy or have a contraindication to beta blocker therapy. Ivabradine is contraindicated with hypotension, sick sinus syndrome, 3rd degree heart block, pacemaker dependence, severe hepatic impairment, and use of cytochrome P4503A4 inhibitors.

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

ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions would be used. Bleeding Precautions, reverse isolation, or Contact Precautions are not necessary.

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? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue

ANS: A, B, C, F Clinical findings of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

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

ANS: A, B, D Acute pericarditis is 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 myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure injuries do not increase clients' risk for acute pericarditis.

A nurse prepares to discharge a client who has heart failure. Which questions would the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) 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?"

ANS: A, B, D To ensure safety upon discharge, the nurse would assess for structural barriers to functional ability, such as stairs. The nurse would also assess the client's available social support, which may include family, friends, and home health services. The client's beliefs about and ability to adhere to medication and treatments, including daily weights, would also be reviewed. The other questions do not specifically address the client's safety upon discharge.

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

ANS: A, B, E Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. These include crackles, confusion (due to decreased oxygenation), and cough. Right ventricular failure is associated with pulmonary hypertension, edema, and jugular venous distention.

A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L (130 mmol/L) c. Serum potassium: 4.0 mEq/L (4.0 mmol/L) d. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L) e. Proteinuria f. Microalbuminuria

ANS: A, B, E, F A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L (130 mmol/L) is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is normal and the serum creatinine level is normal.

A nurse collaborates with assistive personnel (AP) 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? (Select all that apply.) 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."

ANS: 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 and output, and use the same scale to weigh the client each morning before breakfast. APs are not qualified to teach clients or assess the need for and provide oxygen therapy.

A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (Select all that apply.) 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™

ANS: 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 patients with obstructive HCM. Strenuous exercise is also prohibited. Echocardiography, radionuclide imaging, and angiocardiography during cardiac catheterization are performed to diagnose and differentiate cardiomyopathies. The CardioMEMS™ device is used with clients who have heart failure.

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) 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."

ANS: A, D, E Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client would be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day. Salt substitutes typically contain potassium, so although they are not strictly banned, clients would have to have their renal function and serum potassium monitored while using them. It would be safer to avoid them.

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, and 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."

ANS: B A client who has heart failure would be taught to conserve energy and given an exercise plan. The client should begin walking 200-400 feet a day at home three times a week. The client should not walk until becoming short of breath because he or she may not make it back home. The lifting restriction is specifically for clients after valve replacements. Protein does help build strength, but this direction is not specific to heart failure.

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

ANS: B Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.

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."

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy would be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open-heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

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."

ANS: B Clients who have had heart transplants must take immunosuppressant therapy for the rest of their lives. The nurse would teach this client to avoid crowds and sick people to reduce the risk of becoming ill him- or herself. These medications do not place clients at risk for bleeding, orthostatic hypotension, or changes in heart rate. Orthostatic hypotension from the denervated heart is generally only a problem in the immediate postoperative period.

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?"

ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath and fatigue. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

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

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other signs and symptoms do not relate to the progression of mitral valve stenosis.

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 symptoms of hypokalemia.

ANS: B Hypotension is a side effect of ACE inhibitors such as captopril. Clients 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 prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with assistive personnel to provide hygiene is not a priority. The client would be encouraged to complete activities of daily living as independently as possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.

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."

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate

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.

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.

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."

ANS: B 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. ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

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? (Select all that apply.) 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 postdischarge nurse visit has 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.

ANS: B, C, D, F National quality measures aim to decrease heart failure readmission by proper preparation for discharge. These measures include :(1) beta blocker prescribed for left ventricular dysfunction at discharge, (2) postdischarge follow-up appointment scheduled within 7 days of discharge with documentation of location, date, and time. (3) care transition record transmitted to next level of care within 7 days of discharge. (4) documentation of discussion of advance directives/advance care planning with a health care provider, (5) documentation of execution of advance directives within the medical record, and (6) postdischarge evaluation of patient for symptom assessment and treatment adherence within 72 hours of discharge (this can occur by phone, scheduled office visit, or home visit)

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 for stroke when you stand up."

ANS: C Because the 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. The other options are false statements and do not correctly address the client's question.

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."

ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, 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 heart failure.

Which assessment finding does the nurse anticipate in a client with right-sided heart failure? (Select all that apply.) A.Pulmonary congestion B.Shortness of breath C.Neck vein distension D.Enlarged abdominal girth E.A third heart sound

ANS: C, D Right ventricular failure is associated with increased systemic venous pressures and congestions, which creates neck vein distension and enlarged abdominal girth. The other options are associated with left-sided heart failure.

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 daily while wearing the same amount of clothing."

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client would be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

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."

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. 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 of 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.

ANS: D Pain from acute pericarditis may worsen when the client lays supine. The nurse would position the client in a comfortable position, which usually is upright and leaning slightly forward. An ice pack and neck rub will not relieve this pain. Dimming the lights will also not help the pain.

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 information about advance directives?"

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though the concerns are not valid. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the client's concerns instead of immediately calling for the chaplain or psychiatrist. The nurse would not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option.

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.

ANS: D The vasodilating effects of nitrates frequently cause clients to have headaches during the initial period of therapy. The nurse would inform the client about this side effect and offer a mild analgesic, such as acetaminophen. The client's headache is not related to hypoxia or dehydration; therefore, applying oxygen and drinking water would not help. The client needs to take the medication as prescribed to prevent angina; the medication would not be held.

The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4 L. C. Place the client in a high-Fowler position. D. Draw arterial blood for arterial blood gas analysis.

C

Which of the following nursing diagnoses would be appropriate for a client with systolic heart failure? Select all that apply. 1. Ineffective peripheral tissue perfusion related to a decreased stroke volume. 2. Activity intolerance related to impaired gas exchange and perfusion. 3. Dyspnea related to pulmonary congestion and impaired gas exchange. 4. Decreased cardiac output related to impaired cardiac filling. 5. Impaired renal perfusion related to a decreased cardiac output.

1, 2, 3, 5. A decrease in cardiac output occurs from a decreased stroke volume with impaired contractility in systolic heart failure. This impairs peripheral and renal perfusion. The impaired perfusion and impaired oxygenation cause the symptoms of activity intolerance. The decreased systolic function causes an increase in residual volume and pressure in the left ventricle. A retrograde buildup of pressure from the left ventricle to the left atria increases hydrostatic pressure in the pulmonary vasculature. This causes a leakage of fluid into the interstitial tissue of the lungs resulting in pulmonary symptoms. With diastolic heart failure, there is impaired ventricular filling due to a rigid ventricle and reduced ventricular relaxation.

When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply. 1. Becoming increasingly short of breath at rest. 2. Weight gain of 2 lb or more in 1 day. 3. High intake of sodium for breakfast. 4. Having to sleep sitting up in a reclining chair. 5. Weight loss of 2 lb in 1 day.

1, 2, 4. The client stating that he would call the physician with increasing shortness of breath, weight gain over 2 lb in 1 day, and having to sleep sitting up, indicates that he has understood the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the physician if he or she had consumed a high-sodium breakfast. Instead the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future.

A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply. 1. Ventricular hypertrophy. 2. Parasympathetic nervous stimulation. 3. Renin-angiotensin-aldosterone system. 4. Jugular venous distention. 5. Sympathetic nervous stimulation.

1, 3, 5. When the heart begins to fail, the body activates three major compensatory systems: ventricular hypertrophy, the renin-angiotensin-aldosterone system, and sympathetic nervous stimulation. Parasympathetic stimulation and jugular venous distention are not compensatory mechanisms associated with heart failure.

Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? 1. 5 to 10 minutes. 2. 30 to 60 minutes. 3. 2 to 4 hours. 4. 6 to 8 hours.

1. After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.

When teaching the client about complications of atrial fibrillation, the nurse should instruct the client to avoid which of the following? 1. Stasis of blood in the atria. 2. Increased cardiac output. 3. Decreased pulse rate. 4. Elevated blood pressure.

1. Atrial fibrillation occurs when the sinoatrial node no longer functions as the heart's pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not associated with increased cardiac output, elevated blood pressure, or decreased pulse rate; rather, it is associated with an increased pulse rate.

Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of: 1. A manual toothbrush. 2. An electric toothbrush. 3. An irrigation device. 4. Dental floss.

1. Daily dental care and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the bloodstream, increasing the risk of endocarditis.

For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? 1. Ensure a liberal fluid intake. 2. Provide an alkaline-ash diet. 3. Prevent constipation. 4. Enrich the client's diet with dairy products

1. In an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi.

The major goal of therapy for a client with heart failure and pulmonary edema should be to: 1. Increase cardiac output. 2. Improve respiratory status. 3. Decrease peripheral edema. 4. Enhance comfort.

1. Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.

A 69-year-old female has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema. On admission of this client, which of the following should the nurse assess first? 1. Blood pressure. 2. Skin breakdown. 3. Serum potassium level. 4. Urine output.

1. It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown on admission; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.

The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: 1. Observe careful hand-washing procedures. 2. Clean the incisional area with an antiseptic. 3. Use prepackaged sterile dressings to cover the incision. 4. Place soiled dressings in a waterproof bag before disposing of them.

1. Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.

A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time? 1. Medication therapy. 2. Diet modification. 3. Activity restrictions. 4. Dental care.

1. Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprostheses are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent the recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does.

The nurse is admitting a 68-year-old male to the medical floor. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? 1. Assess respiratory status. 2. Draw blood for laboratory studies. 3. Insert a Foley catheter. 4. Weigh the client.

1. The ankle edema suggests fl uid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.

Three days after mitral valve surgery, a 45-year-old female comments that she hears a "clicking" noise coming from her chest and her "rather large" chest incision. The nurse's response should reflect the understanding that the client may be experiencing which of the following? 1. Anxiety related to altered body image. 2. Anxiety related to altered health status. 3. Altered tissue perfusion. 4. Lack of knowledge regarding the postoperative course.

1. Verbalized concerns from this client may stem from her anxiety over the changes her body has gone through after open heart surgery. Although the client may experience anxiety related to her altered health status or may have a lack of knowledge regarding her postoperative course, she is pointing out the changes in her body image. The client is not concerned about altered tissue perfusion.

A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks? Select all that apply. 1. Administer all ordered oral medications. 2. Check for iodine sensitivity. 3. Verify that written consent has been obtained. 4. Withhold food and oral fluids before the procedure. 5. Insert a urinary drainage catheter.

2, 3, 4. For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifi cally ordered. A urinary drainage catheter is rarely required for this procedure.

A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply. 1. Angel food cake. 2. Banana. 3. Dried fruit. 4. Orange juice. 5. Peppers.

2, 3, 4. Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of foods high in potassium. Angel food cake, yellow cake, and peppers are listed by the National Kidney Foundation as low in potassium.

A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply. 1. Begin Warfarin (Coumadin). 2. Check the postoperative CBC, INR, PTT, & platelet levels. 3. Confirm availability of blood products. 4. Monitor the mediastinal chest tube drainage. 5. Start a Dopamine (Intropin) drip for a systolic BP < 100.

2, 3, 4. The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR & PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding, therefore availability of blood products should be confi rmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Coumadin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done fi rst. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.

The nurse finds the apical impulse below the fifth intercostal space. The nurse suspects: 1. Left atrial enlargement. 2. Left ventricular enlargement. 3. Right atrial enlargement. 4. Right ventricular enlargement.

2. A normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.

Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet? 1. Apples. 2. Tomato juice. 3. Whole wheat bread. 4. Beef tenderloin.

2. Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.

Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse should suspect atrial fibrillation when palpation of the radial pulse reveals: 1. Two regular beats followed by one irregular beat. 2. An irregular pulse rhythm. 3. Pulse rate below 60 bpm. 4. A weak, thready pulse.

2. Characteristics of atrial fibrillation include a pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the physician. A weak, thready pulse is characteristic of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction.

A client experiences initial indications of excitation after having an I.V. infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having: 1. Palpitations. 2. Tinnitus. 3. Urinary frequency. 4. Lethargy.

2. Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, seizures, and fi nally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine.

A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing which of the following? 1. Dilated coronary arteries. 2. Increased myocardial contractility. 3. Decreased cardiac arrhythmias. 4. Decreased electrical conductivity in the heart.

2. Digoxin is a cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases the output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat arrhythmias and does decrease the electrical conductivity of the myocardium, these are not the primary reasons for its use in clients with heart failure and pulmonary edema.

A client has a history of heart failure and has been taking several medications, including furosemide (Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows a first-degree atrioventricular block. The nurse should assess the client for signs of which condition? 1. Hyperkalemia. 2. Digoxin toxicity. 3. Fluid defi cit. 4. Pulmonary edema.

2. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fl uid defi cit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.

Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of post-surgery activity restrictions. Which of the following should the client not engage in until after the 1-month post-discharge appointment with the surgeon? 1. Showering. 2. Lifting anything heavier than 10 lb. 3. A program of gradually progressive walking. 4. Light housework.

2. Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge.

A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority? 1. Assess the 12-lead EKG. 2. Assess the blood pressure. 3. Assess the lung sounds. 4. Assess the urine output.

2. The nurse should immediately assess the blood pressure since Nipride and Lasix can cause severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the Nipride dose should be reduced or discontinued. Urine output should then be monitored to make sure there is adequate renal perfusion. A 12-lead EKG is performed if the client experiences chest pain. A reduction in pulmonary artery pressures should improve the pulmonary congestion and lung sounds.

A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action? 1. A low, grade 1 intensity mitral regurgitation murmur. 2. SpO2 is 94% on 2 liters of oxygen via nasal cannula. 3. The client has become more somnolent. 4. Urine output has decreased from 60 mL/hour to 40 mL over the last hour.

3. A complication of balloon valvuloplasty is emboli resulting in a stroke. The client's increased drowsiness should be evaluated. Some degree of mitral regurgitation is common after the procedure. The oxygen status and urine output should be monitored closely, but do not warrant concern.

A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial postprocedure nursing assessment for this client? 1. Monitor the laboratory values. 2. Observe neurologic function every 15 minutes. 3. Observe the puncture site for swelling and bleeding. 4. Monitor skin warmth and turgor.

3. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.

The nurse should teach the client that signs of digoxin toxicity include which of the following? 1. Rash over the chest and back. 2. Increased appetite. 3. Visual disturbances such as seeing yellow spots. 4. Elevated blood pressure.

3. Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with digoxin toxicity.

A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to: 1. Decrease circulatory overload. 2. Improve the myocardial workload. 3. Prevent thrombus formation. 4. Regulate cardiac rhythm.

3. Coumadin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Coumadin does not reduce circulatory load or improve myocardial workload. Coumadin does not affect cardiac rhythm.

The nurse's discharge teaching plan for the client with heart failure should stress the importance of which of the following? 1. Maintaining a high-fi ber diet. 2. Walking 2 miles every day. 3. Obtaining daily weights at the same time each day. 4. Remaining sedentary for most of the day.

3. Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 lb or more. This may indicate fl uid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life-threatening. Following a high-fi ber diet is benefi cial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an exercise program for the client, such as walking 2 miles every day, would not be appropriate at discharge. The client's exercise program would need to be planned in consultation with the physician and based on the history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not prescribe an exercise program for the client, a sedentary lifestyle should not be recommended.

The nurse should teach the client who is receiving warfarin sodium that: 1. Partial thromboplastin time values determine the dosage of warfarin sodium. 2. Protamine sulfate is used to reverse the effects of warfarin sodium. 3. International Normalized Ratio (INR) is used to assess effectiveness. 4. Warfarin sodium will facilitate clotting of the blood.

3. INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.

A 70-year-old female is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the client, the nurse would most likely learn that the client's childhood health history included: 1. Chickenpox. 2. Poliomyelitis. 3. Rheumatic fever. 4. Meningitis.

3. Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis. Chickenpox, poliomyelitis, and meningitis are not associated with mitral stenosis.

Which of the following sets of conditions is an indication that a client with a history of left-sided heart failure is developing pulmonary edema? 1. Distended jugular veins and wheezing. 2. Dependent edema and anorexia. 3. Coarse crackles and tachycardia. 4. Hypotension and tachycardia.

3. Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia may occur due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.

In which of the following positions should the nurse place a client with suspected heart failure? 1. Semi-sitting (low Fowler's position). 2. Lying on the right side (Sims' position). 3. Sitting almost upright (high Fowler's position). 4. Lying on the back with the head lowered (Trendelenburg's position).

3. Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client with heart failure. The client in heart failure would not tolerate Trendelenburg's position.

The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a: 1. Low sodium level. 2. High glucose level. 3. High calcium level. 4. Low potassium level.

4. A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity.

In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that: 1. The client will remain in the ICU for 5 days. 2. The client will sleep most of the time while in the ICU. 3. Noise and activity within the ICU are minimal. 4. The client will receive medication to relieve pain.

4. Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replaceent surgery.

The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to help: 1. Prevent electrolyte imbalances. 2. Retard rapid drug absorption. 3. Excrete excessive fluids accumulated during the night. 4. Prevent sleep disturbances during the night.

4. When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.

The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach

A

The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."

A, B, C, D, E

A nurse is caring for an older adult client who is to undergo a percutaneous balloon valvuloplasty. The client's family member asks the nurse to explain the expected outcome of this procedure. Which of the following responses should the nurse give? A. "This will improve blood flow of the coronary arteries." B. "This will assist with the ability to perform activities of daily living." C. "This will prolong the life span of living with this valve disorder." D. "This will reverse the effects to the damaged area.

A. A valvuloplasty improves blood flow through a heart valve by opening the fused commissures and allowing valve leaflets greater mobility. It does not improve blood flow in the coronary arteries. B. CORRECT: Surgery is indicated for older adult clients when manifestations interfere with activities of daily living. C. Surgical interventions can improve the client's quality of life, but they will not necessarily prolong life. D. A valvuloplasty improves blood flow through a heart valve by opening the fused commissures and allowing valve leaflets greater mobility. It does not reverse the damage that has already occurred to the valve.

A nurse is completing the admission physical assessment of a client who has mitral valve insufficiency. Which of the following findings should the nurse expect? A. S4 heart sound B. Petechiae C. Neck vein distention D. Splenomegaly

A. An S1 heart sound is an expected finding in a client who has mitral valve insufficiency. An S4 heart sound is an expected finding for a client who has aortic stenosis. B. Petechiae is an expected finding in a client who has infective endocarditis. C. CORRECT: Neck vein distention is an expected finding in a client who has pulmonary congestion due to mitral valve insufficiency. D. Hepatomegaly, not splenomegaly, is an expected finding in a client who has left-sided heart valve damage.

A nurse is caring for four clients. Which of the following clients should the nurse identify as being at risk of developing rheumatic endocarditis? A. Older adult who has chronic obstructive pulmonary disease B. Child who has streptococcal pharyngitis C. Middle-aged adult who has lupus erythematosus D. Young adult who recently received a body tattoo

A. An older adult who has chronic obstructive pulmonary disease is not at risk for rheumatic endocarditis unless they develop rheumatic fever. B. CORRECT: A child who has streptococcal pharyngitis is at risk for developing rheumatic fever, which could result in rheumatic endocarditis. C. A middle-age adult who has lupus erythematosus is not at risk for rheumatic endocarditis unless they develop rheumatic fever. D. A young adult who receives a body tattoo is at increased risk for infective endocarditis but is not at risk for rheumatic endocarditis unless they develop rheumatic fever.

A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should expect a prescription for which of the following laboratory tests to assist in confirmation of this diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture

A. Arterial blood gases are used to monitor the respiratory status of a client who has suspected rheumatic endocarditis, but they do not confirm the diagnosis. B. Blood albumin monitors the nutrition status of a client who has a suspected inflammatory disorder, but it does not confirm the diagnosis. C. Liver enzymes monitor a client's response to antibiotic therapy, which is used to treat rheumatic endocarditis, but they do not confirm the diagnosis. D. CORRECT: A throat culture can reveal the presence of streptococcus, which is the leading cause of rheumatic endocarditis.

A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? (Select all that apply.) A. Surgical repair of an atrial septal defect at age 2 B. Measles infection during childhood C. Hypertension for 5 years D. Weight gain of 10 lb in past year E. Diastolic murmur present

A. CORRECT: A history of congenital malformations is a risk factor for valvular heart disease. B. Having a streptococcal infection or rheumatic fever during childhood is a risk factor for valvular heart disease. C. CORRECT: Hypertension places a client at risk for valvular heart disease. D. A sudden weight gain of 10 lb could indicate fluid collection related to left-sided valvular heart disease. E. CORRECT: A murmur indicates turbulent blood flow, which is often due to valvular heart disease.

A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following findings should the nurse include in the discussion? (Select all that apply.) A. Dyspnea B. Client report of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema

A. CORRECT: Dyspnea is a manifestation of right-sided valvular heart disease. B. CORRECT: A client's report of fatigue is a manifestation of right-sided valvular heart disease. C. A normal or rapid pulse and an irregular thythm are manifestations of right-sided velvular heart disease. D. A pleural friction rub is a manifestation of pleurisy or pneumonia. E. CORRECT: Peripheral edema is a manifestation of right-sided valvular heart disease.

A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat pericarditis. Which of the following laboratory findings should the nurse report to the provider? A. Platelets 100,000/mm3 B. Serum glucose 110 mg/dL C. Serum creatinine 0.7 mg/dL D. Amino alanine transferase (ALT) 30 |U/L

A. CORRECT: Long-term NSAID therapy can lower platelets. This finding is outside the expected reference range and should be reported to the provider. B. Blood glucose is not affected by long-term NSAID therapy. This finding is within the expected reference range. C. Kidney function, which is monitored by blood creatinine level, is affected by long-term NSAID therapy. This finding is within the expected reference range. D. Liver function, which is monitored by the ALT level, is affected by long-term NSAID therapy. This finding is within the expected reference range.

A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2,000 mL/day. The client asks the nurse how to determine the appropriate amount of fluids they are allowed. Which of the following statements is an appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink." B. "Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day." C. "This is the same as 2 quarts, or about the same as two pots of coffee." D. "Take sips of water or ice chips so you will not take in too much fluid."

A. CORRECT: Pouring the amount of fluid consumed into an empty 2 L bottle provides a visual guide for the client as to the amount consumed and how to plan daily intake. B. Glasses and cups vary in size and can contain more than 8 oz. C. Offering a vague frame of reference does not assist with accurate fluid measurement. D. Suggesting that the client take sips of water or ice chips does not assist with accurate fluid measurement

A nurse is assessing a client who has splinter hemorrhages of the nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic endocarditis

A. CORRECT: Splinter hemorrhages in nail beds and a report of fever are findings associated with infective endocarditis. B. A client who has pericarditis would report chest pain. C. A client who has myocarditis would report a rapid heart rate. D. A client who has rheumatic endocarditis would report joint pain.

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following manifestations are expected findings? (Select all that apply.) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea

A. CORRECT: Tachypnea is an expected finding in a client who has pulmonary edema. B. CORRECT: A persistent cough with pink, frothy sputum is an expected finding in a client who has pulmonary edema. C. Decreased urinary output is an expected finding in a client who has pulmonary edema. D. Pink, frothy sputum is an expected finding in a client who has pulmonary edema. E. CORRECT: Orthopnea is an expected finding in a client who has pulmonary edema.

A nurse is teaching a client who heart failure and new prescriptions for furosemide and digoxin. Which of the following information should the nurse include? (Select all that apply). A. Weigh daily, first thing each morning. B. Decrease intake of potassium. C. Expect muscle weakness while taking digoxin. D. Hold digoxin if heart rate is less than 70/min. E. Decrease sodium intake.

A. CORRECT: Weighing daily when first getting out of bed will assist the client in tracking fluid loss and gain. B. Increase intake of potassium to prevent hypokalemia while taking furosemide, which increases the risk for digoxin toxicity. C. Report muscle weakness while taking digoxin as an indication of possible toxicity. D. Hold digoxin if heart rate less than 50 to 60/min. The provider will prescribe the parameters for the client. E. CORRECT: Decrease sodium intake to prevent fluid retention, which could worsen heart failure manifestations.

A nurse is caring for a client who has heart failure and reports increased shortness of breath. Which of the following actions should the nurse take first? A. Obtain the client's weight. B. Assist the client into high-Fowler's position. C. Auscultate lungs sounds. D. Check oxygen saturation with pulse oximeter.

A. Check the client's weight to monitor for weight gain. However, another action is the priority. B. CORRECT: Using the airway, breathing, and circulation (ABC) priority approach to client care, the first action to take is to assist the client into high-Fowler's position. This will decrease venous return to the heart (preload) and help relieve lung congestion. C. Auscultate lung sounds to monitor for adventitious sounds, such as crackles. However, another action is the priority. D. Check the client's oxygen saturation to monitor for a decrease. However, another action is the priority.

A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction rub

A. Petechiae is an expected finding in a client who has endocarditis. B. A murmur is an expected finding in a client who has myocarditis and endocarditis. C. Rash is an expected finding in a client who has rheumatic endocarditis. D. CORRECT: A friction rub can be heard during auscultation of a client who has pericarditis.

A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements indicates an understanding of the teaching? A. "I will be glad to get back to my exercise routine right away." B. " will have my prothrombin time checked on a regular basis." C. "I will talk to my dentist about no longer needing antibiotics before dental exams. D. "I will continue to limit my intake of foods containing potassium."

A. The client will be on activity limitation for 6 weeks following surgery for a heart valve replacement. B. CORRECT: Anticoagulant therapy with warfarin is necessary for the client following placement of a mechanical heart valve; the client's prothrombin time will be checked on a regular basis. C. Antibiotic therapy is recommended prior to dental work following placement of a heart valve. D. Dietary recommendations include limiting foods containing sodium.