MS2- Module 2- Cardiovascular EAQ Quiz

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. A. Weight loss B. Unusual fatigue C. Dependent edema D. Nocturnal dyspnea E. Increased urinary output

ANS: B, C, D

The spouse of a client who has been newly diagnosed with newly diagnosed with angina tells the nurse, "I guess I'm going to have to cook 2 meals, one for my spouse and one for myself." Which response would the nurse make? A. "A heart-healthy diet includes foods that most people would enjoy eating." B. "As long as you decrease salt and avoid frying foods, no other changes are needed." C. "Buy foods in small amounts to avoid wasting food when cooking 2 different meals." D. "To help your spouse stay on the heart-healthy diet, you should avoid eating at the same time."

ANS: A "A heart-healthy diet includes foods that most people would enjoy eating." Rationale: Heart-healthy diets are low in cholesterol, sodium, and fat, particularly saturated fats, and high in vegetables and fruits; this type of diet is advocated for all individuals. B- Although low salt and avoiding frying foods are part of a heart-healthy diet, there are other components as well. C- Because a heart-healthy diet can be used by both the client and the spouse, there is no need to worry about wasting food. D- Eating is a social activity, and the spouses should be encouraged to share meals.

Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The nurse advises the client to anticipate pain relief will begin within which period of time? A. 1 to 3 minutes B. 4 to 5 seconds C. 30 to 45 seconds D. 10 to 15 minutes

ANS: A 1 to 3 minutes

When caring for an older client who has had multiple recent hospital admissions for heart failure, which action would the nurse take first? A. Ask the client about medication use and activity level at home. B. Suggest discharge to a local assisted living setting with the client. C. Teach the client about the importance of limiting home salt intake. D. Talk with the client about having home health visits after discharge.

ANS: A Ask the client about medication use and activity level at home.

Which nursing action has the highest priority when caring for a client receiving nitroglycerin for the treatment of angina? A. Asking the client to sit or stand slowly B. Monitoring the client's urine output frequently. C. Advising the client to report when experiencing a headache D. Reporting to the health care provider if pain does not subside after 5 minutes.

ANS: A Asking the client to sit or stand slowly Rationale: Nitroglycerin is a potent antihypertensive and antianginal medication. The nurse should instruct the client to sit and stand slowly after taking the medication to prevent orthostatic hypotension. B- After ensuring the client's safety, the nurse should monitor the urine output. C- A headache is a common side effect of nitroglycerin. The client should have a tingling sensation after taking the nitroglycerin, which ensures that the medication is potent. D- Contacting the health care provider may be important if the pain does not subside after five minutes, but the client's immediate safety takes precedence.

Which parameter would the nurse assess in a client with right-sided heart failure? Select all that apply. A. Fluid volume B. Lung sounds C. Mental status D. Respiratory rate E. Peripheral pulses

ANS: A Fluid volume Rationale: Jugular vein distention, edema, ascites, and weight gain would be expected in a client with right-sided heart failure. Therefore, the nurse would assess fluid volume. Crackles when auscultating lung sounds; restlessness and confusion caused by impaired oxygenation; increased, shallow respiratory rate; and pulsus alternans on evaluation of peripheral pulses are associated with left-sided heart failure.

Which diuretic would the nurse anticipate administering to a client admitted with acute pulmonary edema? A. Furosemide B. Chlorothiazide C. Spironolactone D. Acetazolamide

ANS: A Furosemide Rationale: Furosemide acts on the loop of Henle by increasing the excretion of chloride and sodium; is available for intravenous administration; and is more effective than chlorothiazide, spironolactone, and acetasolamide. B- Although it is used in the treatment of edema and hypertension, chlorothiazide is not as efficacious as furosemide. C- Spironolactone is a potassiumn-sparing diuretic; it is less efficacious than thiazide diuretics. D- Acetazolamide is used in the treatment of glaucoma to lower intraocular pressure.

Which medication would the nurse anticipate will be prescribed to relieve anxiety and apprehension in a client with pulmonary edema? A. Morphine B. Phenobarbital C. Hydroxyzine D. Chloral hydrate

ANS: A Morphine Rationale: Morphine binds with the same receptors as natural opiods. However, it has a rapid onset, lowers the blood pressure, decreases pulmonary reflexes, and produces sedation. B- Phenobarbital has a slower onset than morphine and does not affect respirations and blood pressure to the same extent as morphine. C- Hydroxyzine generally is used to control anxiety associated with less acute situations. D- Chloral hydrate is a hypnotic that is not appropriate for the acute situation described.

Sublingual nitroglycerin has been prescribed for a client with unstable angina. Which client response indicates that nitroglycerin is effective? A. Pain subsides as a result of arteriole and venous dilation. B. Pulse rate increases because the cardiac output has been stimulated. C. Sublingual area tingles because sensory nerves are being triggered. D. Capacity for activity improves a response to increased collateral circulation.

ANS: A Pain subsides as a result of arteriole and venous dilation.

When a client with heart failure is to be discharged and tells the nurse that there are no family members who can help with care at home, which action would the nurse take first? A. Question the client about current support systems. B. Ask the health care provider for a home health referral. C. Suggest short-term placement in a long-term care facility. D. Recommend that the client consider an assisted living facility.

ANS: A Question the client about current support systems.

Which topic will the nurse include in teaching for a client with Raynaud disease? A. Tobacco avoidance B. Dietary salt reduction C. Need for increased exercise D. Low-fat, low-cholesterol diet

ANS: A Tobacco avoidance Rationale: The symptoms of Raynaud disease are caused by sudden arterial vasoconstriction and tobacco use also causes arterial vasoconstriction, which will worsen symptoms. B- Dietary salt is not a factor in causing the sudden arterial spasm that leads to the symptoms of Raynaud disease. C- There is no indication for increased exercise in Raynaud disease, although the nurse will teach the client to avoid exercising in cold temperatures. D- Raynaud disease is not caused by atherosclerosis, and a low-fat, low-cholesterol diet will not help prevent symptoms.

Which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? Select all that apply. A. Crackles B. Coughing C. Orthopnea D. Yellow sputum E. Dependent edema

ANS: A, B, C A. Crackles B. Coughing C. Orthopnea Rationale: Fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Sitting upright while leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. C- Yellow sputum indicates infection, not pulmonary edema. D- With pulmonary edema the sputum may be frothy and blood tinged. Pulmonary interstitial edema, not dependent edema, occurs.

A child with pulmonary edema is treated with opioids and furosemide. Which nursing interventions would the nurse perform to promote safe medication administration? Select all that apply. A. Following the principle of atraumatic care B. Administering oral drugs with food or snacks C. Documenting the client's age, weight, and height D. Exposing the child to sunlight for healthy growth E. Administering medications if the client reports dizziness or drowsiness

ANS: A, B, C Rationale: A local anesthetic should be applied at the injection site to promote atraumatic care. Administering drugs with food reduces gastric discomfort. The client's afe, weight, and height should be documented to help ensure correct calculation of the medication dose. D- A child who is undergoing treatment with diuretics should not be exposed to sunlight because this can cause fluid volume loss and exhaustion. E- If the client reports dizziness or drowsiness, medications should not be administered until a prescription is prescribed by the primary health care provider.

The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. A. Daily weight B. Intake and output C. Monitor for edema D. Daily pulse oximetry E. Auscultate breath sounds

ANS: A, B, C, D, E

Which action would the nurse manager employ during implementation and evaluation of a quality improvement project to decrease hospital readmissions for heart failure clients? Select all that apply. A. Meeting regularly with staff throughout project implementation B. Using readmission data for heart failure clients to evaluate project effectiveness C. Collaborating with staff to address continuing high readmission rates post-project implementation D. Ensuring that staff are provided time to participate in development and implementation of the new project E. Coaching staff on effective implementation of the transition of care for heart failure clients being discharged.

ANS: A, B, C, D, E

Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. A. Fatigue B. Orthopnea C. Pitting edema D. Dry hacking cough E. 4-pound weight gain

ANS: A, B, C, D, E

Which action would the nurse include in the plan of care for a a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. A. Diuretics B. Low-salt diet C. Daily weight checks D. Fluid restriction E. Intake and output F. Oxygen administration

ANS: A, B, C, D, E, F

Which instructions will the home health nurse include when teaching a client with peripheral artery disease? Select all that apply. A. "Avoid crossing your legs." B. "Inspect your feet daily." C. "Change positions slowly." D. "Do not use compression stockings." E. "Avoid green leafy vegetables in your diet."

ANS: A, B, D Rationale: A & D- Crossing the legs and using compression stockings will restrict blood flow, so these actions should be avoided in clients with peripheral artery disease. B- Inspection of the feet is done daily to detect injury, infection, or skin breakdown. C- Changing position slowly is not necessary for clients with peripheral artery disease, although it is recommended for those on medications that cause orthostatic hypotension. D- Dark green leafy vegetables are avoided by clients who take warfarin.

Which suggestion would the nurse make for a client with heart failure? A. "Take a hot bath before bedtime." B. "Avoid emotionally stressful situations." C. "Avoid sleeping in an air-conditioned room." D. "Exercise daily to a pulse rate of 100 beats/minute."

ANS: B "Avoid emotionally stressful situations. "

When an older client with heart failure is transferred from the emergency department to the medical service, which would the nurse on the unit do first? A. Interview the client for a health history. B. Assess the client's heart and lung sounds. C. Monitor the client's peripheral pulse quality. D. Obtain the client's blood specimen for electrolytes

ANS: B Assess the client's heart and lung sounds.

Which position would the nurse plan to use for the client who is having a hypertensive crisis and evolving stroke? A. Supine B. Side-lying C. Orthopneic D. Trendelenburg

ANS: B Side-lying Rationale: The side-lying position will neither raise intracranial pressure nor interfere with respirations and will permit oral secretions to drain from the mouth by gravity. A- The supine position can compromise the airway by permitting the tongue to fall to the posterior pharynx and obstruct the airway. C- The orthopneic position may place pressure on the brainstem. D- The Trendelenburg position is contraindicated because it may increase intracranial pressure.

A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The health care provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. Which nursing action will best evaluate the effectiveness of the furosemide in the managing the client's condition? A. Performing daily weights B. Auscultating breath sounds C. Monitoring intake and output D. Assessing for dependent edema

ANS: B Auscultating breath sounds Rationale: Maintaining adequate gas exchange and minimizing hypoxia with pulmonary edema are critical; therefore assessing the effectiveness of furosemide therapy as it relates to the respiratory system is most important. Furosemide inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule, causing diuresis; as diuresis occurs fluid moves out of the vascular compartment, thereby reducing pulmonary edema and the bilateral crackles.

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

ANS: B Decreased fluid retention Rationale: The purpose of a low-sodium diet for clients with heart failure is to decrease fluid retention. A- Clients with heart failure may or may not need weight loss, but a low-sodium diet will not help with weight control. C-Although sodium restriction may lower blood pressure in clients with hypertension, because of the Frank-Starling law, lower sodium intake may lead to improved cardiac output and higher blood pressures in clients with heart failure. D- Dietary sodium intake plays very little role in serum sodium levels (high serum sodium levels is called hypernatremia), which are controlled by multiple hormonal mechanisms, including antidiuretic hormone, aldosterone, and natriuretic peptide.

When caring for a client who presents to the emergency department with an ST-segment-elevation myocardial infarction (STEMI), which laboratory result will the nurse expect? A. Decreased white blood cell count B. Elevated serum troponins I and T C. Decreased creatine kinase-MB (CK-MB) D. Decreased B-type natriuretic peptide (BNP)

ANS: B Elevated serum troponins I and T Rationale: Elevations of troponin I and T levels are indicative and specific for cardiac muscle damage as would occur with STEMI. A- White blood cell count would increase in the first days after myocardial infarction because of the inflammatory response associated with myocardial cell death. C- CK-MB is found in cardiac muscle and levels increase with myocardial cell death. D- BNP levels are not directly reflective of myocardial infarction, but might increase if the client develops heart failure as complication of myocardial infarction.

Which finding for a client with pulmonary edema who received furosemide is the best indicator that the treatment has been effective? A. Urine output over 1 hour is 200 mL. B. Oxygen saturation per pulse oximetry is 99%. C. Cardiac monitor shows sinus rhythm, rate 98 beats/minute. D. No jugular vein distention is seen with head elevated to 90 degrees.

ANS: B Oxygen saturation per pulse oximetry is 99%. Rationale: Because pulmonary congestion associated with pulmonary edema causes severe hypoxemia, the client's oxygen saturation is the best indicator of effective treatment. A- A good urine output also shows that furosemide is effective, but is not as clear as an indicator of improvement in pulmonary edema as the high oxygen saturation. C- Tachycardia is a common finding with pulmonary edema and having a heart rate in the high normal range may indicate improvement in the client's condition, but improvement in pulmonary parameters is a better indicator for this client. D- Jugular vein distension is an indicator of right heart failure, whereas pulmonary edema is caused by left ventricular failure.

Which information is most important to include when the nurse is teaching a client who has had an ST segment elevation myocardial infarction (STEMI) about the purpose of salt restriciton? A. Low salt intake helps prevent ankle swelling. B. Salt intake increases the work of the heart. C. Decreasing salt intake will lower blood pressure. D. Salt intake prevents diuretics from being effective.

ANS: B Salt intake increases the work of the heart. Rationale: After STEMI, changes in cardiac contractility may lead to chronic heart failure; some of these changes can be prevented by decreasing cardiac work through lowering fluid retention. A- Although a high salt intake may lead to ankle edema, this is not the most important point to emphasize with this client. C- A decrease in salt intake will help lower blood pressure, but decreasing blood pressure is not the most important reason for salt restriction in this client. D- Many diuretics do work by increasing sodium excretion, but improving the effectiveness of diuretics is not the most relevant reason for low salt diet in this client.

When teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider, which clinical manifestations would the nurse include? Select all that apply. A. Weight loss B. Extreme fatigue C. Coughing at night D. Excessive urination E. Difficulty breathing

ANS: B, C, E

When teaching a client who has a new diagnosis of Raynaud disease, which information will the nurse include? Select all that apply. A. Medications will be needed to control the symptoms. B. Stop cigarette smoking and other tobacco use. C. Wear gloves when getting food from the freezer. D. Plan to take a daily low-dose aspirin tablet. E. Avoid going quickly from a warm to a cold environment.

ANS: B, C, E Rationale: Tobacco use increases the vasospasm that causes Raynaud disease symptoms. Use of gloves when handling cold foods helps prevent triggering of vasospasm in the fingers. Moving quickly from a warm to a cold environment may trigger vasospasm and cause symptoms. A- Medications such as calcium channel blockers are only used after lifestyle changes are unsuccessful in relieving symptoms. D- Low-dose aspirin is not used for treatment of Raynaud disease.

Which activities might cause chest pain in a client with stable angina? Select all that apply. A. Deep breathing during meditation B. Walking outside on a cold day C. Sexual activity D. Taking an afternoon nap E. Smoking a cigarette F. Use of an oral decongestant

ANS: B, C, E, F

Which instructions about the use of nitroglycerin to prevent angina will the nurse provide to a client? A. "At the point when pain first occurs, place two tablets under the tongue." B. "Place one tablet under the tongue before activity, and swallow another if pain occurs." C. "Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs." D. "Place one tablet under the tongue when pain occurs and use an additional tablet after the attack to prevent recurrence."

ANS: C "Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs."

The health care provider prescribes isosorbide dinitrate 10 mg for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. How will the nurse respond?

ANS: C "It decreases cardiac oxygen demand." Rationale: Isosorbide dinitrate dilates peripheral veins and arteries thus decreasing preload and decreasing oxygen demand. A- Preventing blood from clotting is the action of anticoagulants. B- Suppressing irritability in the ventricles is the action of antidysrhythmics. D- Increasing the force of contraction of the heart is the action of cardiac glycosides.

When the primary health care provider prescribes "bathroom privileges only" for a client with an exacerbation of heart failure, the client becomes irritable and asks why bed rest is needed. Which response by the nurse is best? A. "Why do you want to be out of bed?" B. "Bed rest plays a role in most therapy." C. "Rest reduces the amount of work your heart has to do right now." D. "Maybe the primary health care provider will increase your activity tomorrow."

ANS: C "Rest reduces the amount of work your heart has to do right now."

Which response by the nurse is best when a client who has had an ST segment elevation myocardial infarction (STEMI) asks about the resumption of sexual activity? A. "You can safely resume sexual activities when you are no longer fearful of sexual intimacy." B. "You will be able to discuss sexual activity with the health care provider before discharge." C. "Sexual activities can be safely resumed after an exercise stress test with no heart symptoms." D. "Many clients wait a few weeks after myocardial infarction before having any sexual activity."

ANS: C "Sexual activities can be safely resumed after an exercise stress test with no heart symptoms." Rationale: Cardiac stress testing is done in clients who have had STEMI before discharge or at a follow-u[ visit soon after discharge, and exercise tolerance is a good indicator of how well the client can tolerate the increased cardiac workload of sexual activity. A- Fear of sexual intimacy is common after STEMI for both the client and spouse, but is unlikely to easily decrease without more information from the nurse or health care provider. B- Telling the client that the health care provider will discuss sexual activity before discharge will discourage further communication of concerns. D- Although many clients do wait a few weeks after myocardial infarction before resuming sexual activity, this response is not specific to this client and discourages further discussion of specific client concerns and questions.

How can the nurse describe heart failure to a client? A. A cardiac condition caused by inadequate circulating blood volume B. An acute state in which the pulmonary circulation pressure decreases C. An inability of the heart to pump blood in proportion to metabolic needs D. A chronic state in which the systolic blood pressure drops below 90 mm Hg

ANS: C An inability of the heart to pump blood in proportion to metabolic needs Rationale: As the heart fails, cardiac output decreases; eventually the decrease will reach a level that pevents tissues from receiving adequate oxygen and nutrients, and it will result in the heart's inability to pump blood in proportion to metabolic needs. A- Heart failure is related to an increased, not decreased or inadequate, circulating blood volume. B- The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. D-The blood pressure may be decreased with heart failure, but a systolic blood pressure below 90 mm Hg can occur in healthy clients or be caused by many other diagnoses.

Which information about a client who is being charged 3 days after having an ST segment elevation myocardial infarction (STEMI) and coronary artery stent placement indicates that a home health referral may be needed at discharge? A. ST segments have not yet returned to baseline. B. Troponin T and Troponin I levels are still elevated. C. Client reports frequently forgetting to take medications. D. Pulse increases from 65 beats/minute to 75 beats/minute with exercise.

ANS: C Client reports frequently forgetting to take medications. Rationale: Because clients are discharged on multiple medications after experiencing STEMI and stenting, the statement about forgetting to take medications indicates a need for home health assessment and interventions to ensure medication adherence. A- ST segments may not return to baseline for a few days after STEMI. B- Troponin levels remain elevated for 10 to 14 days post-STEMI. D- A pulse rate increase of 10 beats/minute is a normal response to exercise.

When assessing a client with heart failure for activity tolerance, which activity would the nurse expect to cause the most distress for the client? A. Getting up from bed in the morning B. Walking to visit the next-door neighbor C. Climbing a flight of stairs to the bedroom D. Leaving the table immediately after a meal

ANS: C Climbing a flight of stairs to the bedroom

Which finding about a client's angina is most important for the nurse to communicate to the health care provider? A. Causes mild perspiration B. Occurs after moderate exercise C. Continues after rest and nitroglycerin D. Precipitates discomfort in the arms and jaw

ANS: C Continues after rest and nitroglycerin Rationale: When neither rest nor nitroglycerin relieves the pain, the client may be experiencing acute coronary syndrome and need rapid diagnostic testing and actions to treat coronary occlusion. A- Mild perspiration may occur with angina, but it should resolve with nitroglycerin or rest. B- Angina that occurs after exercise is probably stable angina and may indicate a need to adjust antianginal medications, but it does not require immediate communication with the health care provider. D- Some clients may have angina that radiates to the arms and jaw. This will be reported to the health care provider, but it does not require any immediate change in the plan of care.

Which assessment finding indicates a need for the nurse to consult with the health care provider before administering the prescribed metoprolol to a client with stable angina? A. Blood pressure 143/90 mm Hg B. Report of chest pain when walking C. Sinus bradycardia, rate 54 on monitor D. Large Q waves on electrocardiogram

ANS: C Sinus bradycardia, rate 54 on monitor Rationale: Because beta blockers such as metoprolol decrease heart rate, the nurse would communicate with the health care provider before giving metoprolol to a client with a slow heart rate. A- Administration of metoprolol to a client with a mildly elevated blood pressure is appropriate, because beta blockers lower blood pressure. B- Chest pain with exertion indicates possibly myocardial ischemia and metoprolol will decrease cardiac oxygen demand and ischemia. D- Large Q waves on the electrocardiogram indicate that the client may have a history of myocardial infarction and metoprolol is appropriate to prevent further ischemia.

The nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema would the nurse initially assess? A. Proteinemia B. Contractures C. Tissue ischemia D. Thrombus formation

ANS: C Tissue ischemia Rationale: Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia, and should be assessed first. A & B- Proteinemia and contractures are not complications resulting from long-term edema. D- Although thrombus formation may occur, the initial assessment is perfusion (tissue ischemia).

A client is admitted to the medical unit with pulmonary edema. The registered nurse (RN) admits the client, writes a plan, and assigns the work to another RN. Which factors are transferable in this case? Select all that apply. A. Authority B. Supervision C. Responsibility D. Accountability E. Communication

ANS: C, D C. Responsibility D. Accountability Rationale: Responsibility and accountability are transferred in this situation because the RN assigns the work to the other RN for the care of the client for an effective outcome. A- Authority is the ability to perform duties in a specific role. B- Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual's performance of an activity. E- Communication is the right of delegation.

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."

ANS: D "I have trouble breathing when I climb a flight of stairs."

Which finding in a client with a diagnosis of stable angina is most important for the nurse to communicate to the health care provider? A. Anginal symptoms are relieved by rest. B. Discomfort is described as chest pressure. C. Radiation of pain to the left arm and back occurs. D. Angina episodes are occurring more frequently.

ANS: D Angina episodes are occurring more frequently. Rationale: Increasing frequency of anginal episodes may indicate unstable angina and acute coronary syndrome, which requires urgent treatment because it is caused by prolonged myocardial ischemia. A- Because rest typically relieves stable angina, this finding does not need to be immediately communicated to the health care provider. B- Clients frequently describe angina as a feeling of chest pressure; this information does not indicate a need for rapid treatment. C- Radiation of pain to the arm or back frequently occurs with angina; this finding would not indicate a need for any change in the client's treatment.

A client who has been admitted with pulmonary edema and received furosemide intravenously needs to void. Which action by the nurse would be best? A. Place the client on a bedpan. B. Use adult diapers for the client. C. Help the client walk to the bathroom. D. Assist the client to a bedside commode.

ANS: D Assist the client to a bedside commode. Rationale: Assisting the client to a bedside commode allows the client to keep the head elevated, which is needed in clients with pulmonary edema to improve oxygenation. A- Placing a bedpan will require that the head of the bed be lowered so that the bedpan can be placed and will increase the client's work of breathing. B- Using adult diapers on client who is not incontinent is disrespectful and demeaning to the client. C- Having the client walk to the bathroom will increase cardiac workload, which should be avoided in clients with pulmonary edema.

Which finding would the nurse expect when caring for a client with right-sided heart failure? A. Oliguria B. Pallor C. Cool extremities D. Distended neck veins

ANS: D Distended neck veins Rationale: Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. A- Oliguria is caused by decreased renal perfusion associated with left ventricular failure. B- Pallor is caused by decreased systemic perfusion secondary to left ventricular failure. C- Cool extremities are a symptom of decreased systemic perfusion associated with left ventricular failure.

Which would the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? A. Encourage frequent coughing. B. Elevate the client's lower extremities. C. Prepare for modified postural drainage. D. Place the client in the orthopneic position.

ANS: D Place the client in the orthopneic position. Rationale: The orthopneic, or tripod position, allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. A- Coughing is useful for clients who have excessive mucus in the airways, such as clients with pneumonia, but is not useful for clearing pulmonary edema. B- Elevation of the extremities should be prevented because it increases venous return, placing an increased workload on the heart. C- Positioning for postural drainage does not relieve acute dyspnea; furthermore, it increases venous return to the heart.

Which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin? A. Apical pulse rate 96 beats/minute B. Bilateral foot and ankle pitting edema C. Crackles heard at the base of both lungs D. Potassium level of 2.3 mEq/L (2.3 mmol/L)

ANS: D Potassium level of 2.3 mEq/L

Which pain characteristic would the nurse expect to observe when a client is experiencing anginal pain? A. Unchanged by rest B. Precipitated by light activity C. Described as a knifelike sharpness D. Relieved by sublingual nitroglycerin

ANS: D Relieved by sublingual nitroglycerin

A neonate with heart failure is prescribed furosemide. Which changes to the dosage or time intervals between doses would the nurse make? A. The dosage should be doubled. B. The dosage should be cut in half. C. The time between doses should be shortened. D. The time between doses should be lengthened.

ANS: D The time between doses should be lengthened.