Chapter 25: Management of Patients with Complications of Heart Disease
The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse?
Call for help and begin chest compressions.
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?
"I sleep on three pillows each night."
The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home?
"I'm having trouble going up the steps during the day."
A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be?
30%
A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action?
Administer epinephrine.
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
BP and pulse measurements every 15 to 30 minutes
The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure?
Brain natriuretic peptide (BNP)
Which is a key diagnostic indicator of heart failure?
Brain natriuretic peptide (BNP)
A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?
Call for a chest x-ray.
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
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?
Dizziness
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
Dyspnea on exertion
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
Echocardiogram
A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence?
Excess pericardial fluid compresses the heart and prevents adequate diastolic filling.
The nurse visits the home of a client with heart failure. Which assessment finding indicates to the nurse that the client's tolerance to activity is deteriorating?
Fatigue after walking to answer the door
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
The nurse is preparing to administer hydralazine and isosorbide dinitrate. 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 health care provider.
Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?
IV
A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client?
Intubation and mechanical ventilation
Which is a characteristic of right-sided heart failure?
Jugular vein distention
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?
Pulmonary congestion
A client has been diagnosed with heart failure. What is the major nursing outcome for the client?
Reduce the workload on the heart.
A client with heart failure reports a sudden change in the ability to perceive colors. The client reports nausea, and assessment reveals an irregular pulse of 39 beats per minute. What is the nurse's best action?
Report the possibility of digitalis (digoxin) toxicity to the care provider promptly
The nurse recognizes which symptom as a classic sign of cardiogenic shock?
Restlessness and confusion
Which is a potassium-sparing diuretic used in the treatment of heart failure?
Spironolactone
Which is a manifestation of right-sided heart failure?
Systemic venous congestion
What disease process(es) contributes to chronic heart failure? Select all that apply.
Tachyarrhythmias Valvular disease Renal failure
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 reports 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 what condition?
acute pulmonary edema.
A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals coarse crackles in the lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing
decompensated heart failure with pulmonary edema.
The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided heart failure?
ascites
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:
canned peas.
The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy?
decreased left ventricular workload
Frequently, what is the earliest symptom of left-sided heart failure?
dyspnea on exertion
The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion?
inadequate cardiac output
A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. Which finding indicates a need for immediate attention?
lung congestion
The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure?
pitting edema
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.
A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?
visual disturbances.
