Chapter 25 med surg prep u

A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be?

30%

The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg?

Administer the third sublingual nitroglycerin tablet.

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?

Arterial blood gases

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

A health care provider in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?

Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours

A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved?

Decrease in central venous pressure (CVP)

The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs?

Dopamine Dopamine, a sympathomimetic drug, is used to treat cardiogenic shock. It increases perfusion pressure to improve myocardial contractility and blood flow through vital organs. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and doesn't have a direct effect on contractility or tissue perfusion. Metoprolol is a beta-adrenergic blocker that slows heart rate and lowers blood pressure, undesirable effects when treating cardiogenic shock.

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.

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 performing an initial assessment of a client diagnosed with heart failure. The nurse also assesses the client's sensorium and LOC. Why is the assessment of the client's sensorium and LOC important in clients with heart failure?

Heart failure ultimately affects oxygen transportation to the brain.

The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with ordinary physical activity. Under what classification does the nurse understand this patient would be categorized?

II

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?

JVD is noted 4 cm above the sternal angle.

The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What would be an important instruction for the nurse to give a client who is to undergo a MUGA scan?

Lie very still at intermittent times during the test.

A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)?

Myocardial ischemia Myocardial dysfunction and HF can be caused by a number of conditions, including coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Atherosclerosis of the coronary arteries is a primary cause of HF, and coronary artery disease is found in the majority of clients with HF. Ischemia causes myocardial dysfunction because it deprives heart cells of oxygen and causes cellular damage. MI causes focal heart muscle necrosis, myocardial cell death, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Left-sided heart failure is caused by myocardial ischemia. Ineffective right ventricular contraction, pulmonary embolus, and cystic fibrosis cause right-sided heart failure.

What is the main difference between Class I and Class II heart failure as defined by the New York Heart Association (NYHA)?

The level of physical activity each allows

The student nurse is caring for a client with heart failure. Diuretics have been prescribed. What method might be used with a debilitated client to help the nurse evaluate the client's response to diuretics?

Using a urinary catheter

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

The nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will decrease preload?

administration of a vasodilating drug (as ordered by a health care provider)

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

A client is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client?

digoxin immune FAB

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

The nurse is interviewing a client during an initial visit at a cardiologist's office. What symptom will the nurse expect to find as an early symptom of chronic heart failure?

fatigue

The critical care nurse is caring for a client with cardiogenic shock. What is the premise for inserting an intra-aortic balloon pump?

inadequate tissue perfusion

The pathophysiology of pericardial effusion is associated with all of the following except:

increased venous return

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

A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis?

orthopnea

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective?

peripheral edema

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?

preload

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." What additional assessment information would be important for the CSU nurse to obtain?

pulmonary crackles

A client taking an ACE inhibitor has developed a dry, hacking cough. Because of this side effect, the client no longer wants to take that medication. What medication that has similar hemodynamic effects does the nurse anticipate the health care provider ordering?

valsartan

A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?

weight