PrepU Ch. 29
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?
"I sleep on three pillows each night." Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing.
A patient is admitted to the hospital and is being evaluated for heart failure. Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
Echocardiogram
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding?
?"Experiences exertional dyspnea when walking 3 feet; states, ?"I cannot catch my breath."
The nurse is assigned to care for a patient with heart failure. What classification of medication does the nurse anticipate administering that will improve symptoms as well as increase survival?
ACE inhibitor
A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing intervention?
Assess oxygen saturation
A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?
Class I (Mild)
Which assessment parameter is important for the client diagnosed with congestive heart failure?
Distended veins
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
Echocardiogram
Which describes difficulty breathing when a client is lying flat?
Orthopnea
A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?
Potassium
Which of the following would be inconsistent as a lifestyle change directive for the patient diagnosed with heart failure?
Push fluids
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?
The development of left-sided heart failure
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?
Ventricular assist device (VAD)
Which nursing intervention should the nurse perform when a client with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta-blockers?
Withhold the drug and inform the primary health care provider.
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:
canned peas.
A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?
echocardiogram
A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth daily, and furosemide (Lasix), 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause:
visual disturbances.
The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information?
"Are you only able to breathe when you are sitting upright?"
A patient has been experiencing increasing shortness of breath and fatigue. The physician has ordered a diagnostic test in order to determine what type of heart failure the patient is having. What diagnostic test does the nurse anticipate being ordered?
An echocardiogram
The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause increased preload. The student correctly answers which of the following?
Application of antiembolytic stockings Preload is the amount of blood presented to the ventricles just before systole. Anything that assists in returning blood to the heart (eg, antiembolytic stockings) or preventing blood from pooling in the extremities will increase preload
The Cardiac Nurse Clinician is teaching a group of clients with heart failure about self-management of their disease. What dietary advice should the Nurse Clinician give to clients with severe heart failure until edema resolves?
Avoid the intake of processed and commercially prepared foods.
The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure?
Brain natriuretic peptide (BNP)
A patient has been admitted to the hospital with exacerbation of heart failure (HF) that has resulted in pulmonary and peripheral edema. The nurse has been carefully monitoring the trajectory of the patient's signs and symptoms of HF. How can the nurse best monitor the patient's fluid balance?
By performing daily weights at the same time each day
The nursing instructor is teaching their clinical group how to assess a client for congestive heart failure. How would the instructor teach the students to assess a client with congestive heart failure for nocturnal dyspnea?
By questioning how many pillows the client normally uses for sleep
A client has been prescribed furosemide (Lasix) 80 mg twice daily. The cardiac monitor technician informs the nurse that the client has started having rare premature ventricular contractions followed by runs of bigeminy lasting 2 minutes. During the assessment, the nurse determines that the client is asymptomatic and has stable vital signs. Which of the following actions should the nurse perform next?
Check the client's potassium level.
The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition?
Crackles are audible on chest auscultation. Patients with HF often exhibit crackles, which are produced by the sudden opening of edematous small airways and alveoli that have adhered together by exudate. These may be heard at the end of inspiration and are not cleared with coughing
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?
Dizziness
A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient?
Potassium levels
The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?
Echocardiogram
The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience?
Gradual unexplained weight gain
A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload?
Head of the bed elevated 45 degrees and lower arms supported by pillows
A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?
Heart failure
Which of the following therapies are for patient who have advanced heart failure (HF) after all other therapies have failed?
Heart transplant
The nurse is preparing to administer hydralazine and isosorbide dinitrate (Dilatrate). When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse?
Hold the medication and call the physician. A combination of hydralazine and isosorbide dinitrate may be another alternative for patients who cannot take ACE inhibitors (ICSI, 2011). Nitrates (e.g., isosorbide dinitrate) cause venous dilation, which reduces the amount of blood return to the heart and lowers preload. Hydralazine lowers systemic vascular resistance and left ventricular afterload. If these medications lead to severe hypotension, the nurse should hold the medication and call the physician.
A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure?
Hypertension causes the heart's chambers to enlarge and weaken.
Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?
IV
The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?
Left ventricular function The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.
A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate?
Morphine sulfate
Nursing management of a client in heart failure with pulmonary edema includes which of the following?
Observation of the effectiveness of emergency drug therapy
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which of the following assessment findings for this client?
Pulmonary congestion
The nurse recognizes which symptom as a classic sign of cardiogenic shock?
Restlessness and confusion Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation)
Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?
Spironolactone
A nurse is administering lanoxin, which she knows increases contractility as well as cardiac output. Contractility refers to which of the following?
The force of the contraction related to the status of the myocardium
A class of beginning nursing students is learning about heart failure in their pathophysiology class. What should the students be taught is the reason for heart failure?
The heart cannot pump sufficient blood to meet the body's metabolic needs.
Which is a classic sign of cardiogenic shock?
Tissue hypoperfusion
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?
Weighing the client daily at the same time each day
A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of:
acute pulmonary edema
A client has been diagnosed with congestive heart failure. This client's cardiac function has been compromised since the client suffered a myocardial infarction 3 years ago. Heart failure is classified by:
amount of activity restriction the failure imposes.
A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment?
moist, gurgling respirations Clients with acute pulmonary edema experience sudden dyspnea, wheezing, orthopnea, cough, cyanosis, and tachycardia. Respirations sound moist or gurgling.
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?
nausea and vomiting
A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of
pulmonary embolism.
