Chapter 29 AH

On his return to the cardiac step-down unit after his diagnostic procedure, a client awaits the report from his cardiologist. As the client's nurse, you review the process of measuring ejection fraction and explain to the client that it measures the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?

55%

Which of the following is a key diagnostic indicator of heart failure?

BNP

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

The nurse identifies which of the following symptoms as a manifestation of right-sided heart failure (HF)?

Congestion in the peripheral tissues

A patient with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, bradycardia, and muffled heart sounds. The senior nursing student recognizes these symptoms occur when

Excess pericardial fluid compresses the heart and prevents adequate diastolic filling.

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

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

Increased venous return.

Which of the following is the hallmark of systolic heart failure?

Low ejection fraction (EF)

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

Which of the following describes difficulty breathing when a patient is lying flat?

Orthopnea

Which of the following is a classic sign of cardiogenic shock?

Tissue hypoperfusion

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as:

a third heart sound (S3)

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:

place the client in high Fowler's position.

Which of the following would be inconsistent as a lifestyle change directive for the patient diagnosed with heart failure?

push fluids

A nurse suspects that a client has digoxin toxicity. The nurse should assess for:

vision changes.

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."

A client is receiving furosemide (Lasix), a loop diuretic, to prevent fluid overload. The order is for 50 mg intraveneous now. The pharmacy supplies Lasix 80 mg per 2 mL. How many mL will the nurse give the client? Enter the correct number ONLY.

1.25

A nurse has come upon an unresponsive, pulseless victim. She has placed a 911 call and begins CPR. The nurse understands that if the patient has not been defibrillated within which time frame, the chance of survival is close to zero?

10 min

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 decreased preload. The student correctly answers which of the following?

Administration of a vasodilating drug (as ordered by a physician)

A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD?

An LVAD only supports a failing left ventricle

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 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?

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 patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention?

Assess oxygen saturation level

A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure?

B-type natriuretic peptide (BNP)

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?

Bibasilar crackles

The nurse recognizes which of the following lab tests 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.

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.

Which pulse should the nurse palpate during rapid assessment of an unconscious adult?

Carotid

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.

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)

A nurse taking care of a patient recently admitted to the ICU observes the patient coughing up large amounts of pink, frothy sputum. Auscultation of the lungs reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this patient is developing which of the following problems?

Decompensated heart failure with pulmonary edema

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

Decrease in central venous pressure (CVP)

Which of the following body system responses correlates with systolic heart failure (HF)?

Decrease in renal perfusion

What is the primary underlying disorder of pulmonary edema?

Decreased left ventricular pumping

Which drug is most commonly used to treat cardiogenic shock?

Dopamine (Intropin)

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.)

Dyspnea Cough Pulmonary crackles

Frequently, what is the earliest symptom of left-sided heart failure?

Dyspnea on exertion

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

The diagnosis of heart failure is usually confirmed by which of the following?

Echocardiogram

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 nursing instructor is discussing heart failure with their clinical group. The instructor talks about heart failure in terms of a decreasing ejection fraction of the heart. What diagnostic test is used to measure the ejection fraction of the heart?

Echocardiogram

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient?

Electrolyte and water loss

A 76-year-old client has a significant history of congestive heart failure. During his semiannual cardiology examination, for what should you, as his nurse, specifically assess? Select all that apply.

Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion.

You are caring for a client with suspected right-sided heart failure. What would you know that clients with suspected right-sided heart failure may experience?

Gradual unexplained weight gain

A patient with congestive heart failure is admitted to the hospital with complaints of shortness of breath. How should the nurse position the patient in order to decrease preload?

Head of the bed elevated at 45 degrees and lower arms supported by pillows

Which of the following therapies are for patient who have advanced heart failure (HF) after all other therapies have failed?

Heart transplant

Sixty six-year-old David Steiner is already being treated for hypertension. His doctor, concerned about the potential for heart failure, has him come back for check-ups regularly. What does hypertension have to do with heart failure

Hypertension causes the heart's chambers to enlarge and weaken.

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

II

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV

Which of the following is the primary cause of pulmonary or peripheral congestion?

Inadequate cardiac output

A nurse reviews the patient's chart. The doctor noted in the progress notes that he suspected the patient was experiencing decreased left ventricular function. The nurse knows to look for documentation of all of the following to validate that diagnosis except:

Increased stroke volume.

A patient seen in the clinic has been diagnosed with stage A heart failure (according to the staging classification of the American College of Cardiology [ACC]). What education will the nurse provide to this patient?

Information about ACE inhibitors and risk factor reduction

Which of the following is a characteristic of right-sided heart failure?

JVD

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

JVD is noted 3 cm above the sternal angle

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

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?

Leg edema

A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?

Low blood pressure triggers the baroreceptors to decrease sympathetic nervous system stimulation.

The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?

Low-sodium diet

A 73-year-old client has been admitted to the cardiac step-down unit where you practice nursing. After diagnostics, she was brought to your unit with acute pulmonary edema. Which of the following symptoms would you expect to find during your assessment?

Moist, gurgling respirations

Which of the following medications is a human brain natriuretic peptide (BNP) preparation?

Natrecor

You are working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for you to closely monitor an older adult receiving digitalis preparations for cardiac disorders?

Older adults are at increased risk for toxicity.

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating which of the following?

Orthopnea

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately?

Persistent cough

The nurse does an assessment on a patient who is admitted with a diagnosis of right-sided heart failure. The nurse knows that a significant sign is which of the following?

Pitting edema

A physician orders digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?

Potassium level of 2.8 mEq/L

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient?

Potassium levels

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

A patient who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly develops complaints of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the patient for other signs and symptoms of which of the following problems?

Pulmonary embolism

The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock?

Restlessness and confusion

A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure?

Right-sided heart failure

A patient has been diagnosed with systolic heart failure. The nurse would expect the patient's ejection fraction to be at which level?

Severely reduced

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?

Spironolactone (Aldactone)

The nurse is discussing cardiac hemodynamics with a nursing student, who understands the following formula: CO = HR X SV (cardiac output equals heart rate times stroke volume). The student asks what determines stroke volume. The correct response by the nurse is which of the following?

Stroke volume depends on three factors: preload, afterload, and contractility.

Which of the following is a manifestation of right-sided heart failure?

Systemic venous congestion

The nurse is administering nitroglycerin, which he knows decreases preload as well as afterload. Preload refers to which of the following?

The amount of blood presented to the ventricles just before systole

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

The client says his rings have become tight and are difficult to remove.

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 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

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 physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer?

Valsartan (Diovan)

A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?

Ventricularassistdevice (VAD)

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

Which of the following nursing interventions should a nurse perform when a patient 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 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.

Ronald is a 46-year-old who has developed congestive heart failure. He has to learn to adapt his diet and you are his initial counselor. Which of the following should you tell him to avoid?

canned peas

Which of the following is a cerebrovascular manifestation of heart failure?

dizziness

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating

orthopnea

A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:

peripheral edema

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