EAQ Quiz 2

When assessing a client with right ventricular heart failure, the nurse would expect which findings? (SATA) A. Dependent edema B. Swollen hands and fingers C. Collapsed neck veins D. Right upper quadrant discomfort E. Oliguria

A. Dependent Edema, B. Swollen hands and fingers, D. Right upper quadrant discomfort Rationale: With right sided heat failure, the signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers (fluid is backing up in the venous system, to tissues and organs). Upper right quadrant discomfort is expected because venous congestion in the systemic circulation results in hepatomegaly (enlarged liver)

Which assessment finding would the nurse expect when a client is diagnosed with left sided congestive heart failure? (SATA) A. Dyspnea B. Crackles C. Frequent cough D. Peripheral edema E. Jugular distention

A. Dyspnea, B. Crackles, C. Frequent cough Rationale: Increases in left ventricular volume and pressure leads to pulmonary congestion, causing dyspnea, lung crackles, and cough.

Which dietary choice would the nurse teach for the client with peripheral arterial disease? (SATA) A. Limit salt intake B. Choose foods high in calcium C. Eat whole grain breads D. Use liquid vegetable oils E. Reduce fresh fruits and vegetables F. Avoid processed meats

A. Limit salt intake, C. Eat whole grain breads, D. Use liquid vegetable oils, E. Avoid processed meats. Rationale: Peripheral arterial disease is caused by atherosclerosis, so the nurse would teach the client heart-healthy principles such as limiting salt, eating whole grains, liquid oils instead of solid, and avoiding processed meats.

When the nurse needs to determine atrial rate and rhythm, which component of the electrocardiogram will be used? A. P waves B. PR intervals C. T waves D. QRS complex

A. P waves Rationale: The p wave represents atrial depolarization and the nurse would use P waves to determine atrial rate and rhythm.

Which finding would the nurse expect when assessing a client with peripheral arterial disease? (SATA) A. Pallor of feet B. Warm extremities C. Ulcers on the toes D. Thick, hardened skin E. Delayed capillary refill

A. Pallor of feet, C. Ulcers on toes, E. Delayed capillary refill Rationale: PAD affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result the extremities exhibit pallor, ulcers on boney prominences, cool skin, and capillary refill longer than 3 sec. Venous disease is what can lead to warm extremities and thick/hard skin.

Which medication prescribed for a client with an acute episode of heart failure would the nurse question? A. Diuretic B. Beta Blocker C. Long-acting nitrate D. Angiotensin receptor blocker

B. Beta Blocker Rationale: Beta blockers reduce cardiac output and are contraindicated for clients with acute heart failure, although they are used to prevent progression of chronic heart failure. (diuretics dec hypervolemia & congestion, nitrates reduce preload, and angiotensin blockers dec fluid overload/afterload)

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low sodium diet? A. Body weight control B. Decreased fluid retention C. Lowering of blood pressure D. Prevention of hypernatremia

B. Decreased fluid retention Rationale: The purpose of a low sodium diet for clients with heart failure is to decrease fluid retention.

Which possible complication would a nurse monitor for when a client develops a venous thrombosis in the left calf? A. Embolic stroke B. Pulmonary embolism C. Myocardial infarction D. Ischemia of the left foot

B. Pulmonary embolism Rationale: Because the venous system returns blood to the right side of the heart and then the blood flows to the pulmonary circular, emboli from the venous thrombosis may cause a pulmonary embolism.

Which finding in a client with right calf venous thrombosis is most important to communicate to the health care provider? A. Severe right calf pain B. Right calf redness and swelling C. Oxygen saturation 89% D. Heart rate of 136 beats/minute

C. Oxygen saturation 89% Rationale: Low oxygen saturation in the setting of venous thrombosis may indicate pulmonary embolism, which will require rapid interventions, such a as actions to improve oxygenation (such improvements would also decrease the heart rate).

When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report? A. Losing weight over the past week B. Tingling in the upper extremities C. Using several pillows to sleep at night D. Wheezing when exposed to dust or pollen

C. Using several pillows to sleep at night Rationale: Heart failure causes pulmonary congestion, leading to orthopnea and the need to elevate the head and chest with pillows when lying down.

Which rhythm would the nurse document when observing the following dysrhythmia on a client's cardiac monitor? A. Atrial flutter B. Atrial fibrillation C. Ventricular fibrillation D. Ventricular tachycardia

C. Ventricular fibrillation Rationale: Ventricular fibrillation refelcts a rapid, feeble twitching/quivering of the ventricles; it has an irregular sawtooth configuration with unidentifiable PR intervals and QRS complexes.

Which action would the nurse take to prevent venous thrombus formation after abdominal surgery? A. Keep the client in a gatch bed to elevate the knees B. Have the client dangle the legs off the side of the bed. C. Help the client use an incentive spirometer every hour. D. Encourage the client to ambulate multiple times daily

D. Encourage the client to ambulate multiple times daily Rationale: Ambulation is essential to promote venous return and prevent thrombus formation. (A gatch bed elevating the knees or dangling legs off the bed increase risk for venous thrombosis.)

Which action would a nurse perform first for a client with a dysrhythmia? A. Monitor oxygen saturation B. Establish intravenous access C. Administer oxygen via a nonrebreather mask D. Ensure airway-breathing-circulation (ABC)

D. Ensure airway-breathing-circulation Rationale: With any life-threatening complication such as dysrhythmias, a client should be assessed for ABCs immediately because the client may be experiencing airway obstruction.

Which statement by a client is consistent with a diagnosis of heart failure? A. "I see spots before my eyes" B. "I am tired at the end of the day" C. "I feel bloated when I eat a large meal" D. "I have trouble breathing when I climb a flight of stairs "

D. I have trouble breathing when I climb a flight of stairs Rationale: Dyspnea on exertion occurs with heart failure because of the heart's inability to meet oxygen needs of the body.

which dysrhythmia would the nurse identify on this client's electrocardiogram (ECG) strip? A. Asystole B. Atrial flutter C. Ventricular fibrillation D. Premature ventricular complexes

D. Premature ventricular complexes Rationale: Beats 2 and 4 are premature ventricular complexes or beats, The impulse originates in the ventricles, and it occurs before the next expected ventricular beat.

Which term would the nurse use to document the rhythm when a clients cardiac rhythm strip shows more P waves than QRS complexes and there is no relationship between atria and the ventricles? A. First degree atrioventricular (AV) block B. Second degree AV block Mobitz I (Wenckebach) C. Second degree AV block Mobitz II D. Third degree AV block (complete heart block)

D. Third degree block is often called "Complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of eachother because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of 3rd degree heart block is the P waves have no association with the QRS complexes and appear throughout the QRS waveform .