Chapter 29
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
What is the primary underlying disorder of pulmonary edema?
Decreased left ventricular pumping
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 minutes
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
Which of the following body system responses correlates with systolic heart failure (HF)?
Decreased renal perfusion
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 levels
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.
Which of the following is a key diagnostic indicator of heart failure?
BNP
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 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
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
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
Which of the following medications reverses digitalis toxicity?
Digoxin immune FAB (Digibind)
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 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
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 a characteristic of right-sided heart failure?
JVD
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 dysfunction
A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?
Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation.
Which of the following medications is a human brain natriuretic peptide (BNP) preparation?
Natrecor
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 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 has been diagnosed with congestive heart failure. Which of the following is a cause of crackles heard in the bases of the lungs?
Pulmonary congestion
Which of the following would be inconsistent as a lifestyle change directive for the patient diagnosed with heart failure?
Push fluids
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.
The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?
Withhold the medication and notify the physician of the heart rate.
A nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:
establish unresponsiveness.
When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating
orthopnea.
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)
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%
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
The nurse understands that a patient with which cardiac arrhythmia is most at risk for developing heart failure?
Atrial fibrillation
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
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 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)
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?
Echocardiogram
The diagnosis of heart failure is usually confirmed by which of the following?
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
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 loss
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
The nurse is preparing to administer furosemide (Lasix) to a client with severe heart failure. What lab study should be of most concern for this client while taking Lasix?
Potassium level of 3.1
The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock?
Restlessness and confusion
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
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).
