Chapter 32: Concepts of Care for Patients with Cardiac Problems

5. A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all clients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other responses do not address the importance of monitoring fluid retention or loss.

21. A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the best response by the nurse? a. "I can stay if you would you like to talk more about this." b. "You are lucky to have such a devoted daughter." c. "It is normal to feel as though you are a burden." d. "Would you like to meet with the chaplain?"

ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the client's concerns and do not allow the nurse to obtain more information to provide client-centered care.

4. While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the primary health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

20. A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? a. "Do you have trouble breathing or chest pain?" b. "Are you still able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"

ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath and fatigue. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

12. A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other signs and symptoms do not relate to the progression of mitral valve stenosis.

7. After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is most important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

ANS: B Hypotension is a side effect of ACE inhibitors such as captopril. Clients with a fluid volume deficit should have their volume replaced or start at a lower dose of the drug to minimize this effect. The nurse would instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with assistive personnel to provide hygiene is not a priority. The client would be encouraged to complete activities of daily living as independently as possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure

9. A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption.

3. The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach

A

1. The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."

A, B, C, D, E

6. A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."

ANS: A Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the client's pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

11. A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first? a. Assess the client's respiratory status. b. Draw blood to assess the client's serum electrolytes. c. Administer intravenous furosemide. d. Ask the client about current medications.

ANS: A Assessment of respiratory and oxygenation status is the most important nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take precedence over assessing respiratory status.

1. A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

ANS: A Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

15. A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation

ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions would be used. Bleeding Precautions, reverse isolation, or Contact Precautions are not necessary.

32. A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue

ANS: A, B, C, F Clinical findings of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

27. A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d. An 80-year-old man with a bacterial infection of the respiratory tract e. An 88-year-old woman with a stage III sacral ulcer

ANS: A, B, D Acute pericarditis is most commonly associated with acute exacerbations of systemic connective tissue disease, including SLE; with Dressler syndrome, or inflammation of the cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure injuries do not increase clients' risk for acute pericarditis

31. A nurse prepares to discharge a client who has heart failure. Which questions would the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" c. "Will you be able to afford your oxygen therapy?" d. "What spiritual beliefs may impact your recovery?" e. "Are you able to accurately weigh yourself at home?"

ANS: A, B, D To ensure safety upon discharge, the nurse would assess for structural barriers to functional ability, such as stairs. The nurse would also assess the client's available social support, which may include family, friends, and home health services. The client's beliefs about and ability to adhere to medication and treatments, including daily weights, would also be reviewed. The other questions do not specifically address the client's safety upon discharge.

25. A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night f. Jugular venous distention

ANS: A, B, E Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. These include crackles, confusion (due to decreased oxygenation), and cough. Right ventricular failure is associated with pulmonary hypertension, edema, and jugular venous distention.

26. A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L (130 mmol/L) c. Serum potassium: 4.0 mEq/L (4.0 mmol/L) d. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L) e. Proteinuria f. Microalbuminuria

ANS: A, B, E, F A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L (130 mmol/L) is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is normal and the serum creatinine level is normal

29. A nurse collaborates with assistive personnel (AP) to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (Select all that apply.) a. "Reposition the client every 2 hours." b. "Teach the client to perform deep-breathing exercises." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning." e. "Place the client on oxygen if the client becomes short of breath."

ANS: A, C, D The AP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The AP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. APs are not qualified to teach clients or assess the need for and provide oxygen therapy.

33. A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (Select all that apply.) a. Administering beta blockers b. Administering high-dose furosemide c. Preparing for a cardiac catheterization d. Loading the client on digitalis e. Instructing the client to avoid strenuous exercise f. Teaching the client how to use the CardioMEMS™

ANS: A, C, E Management of obstructive HCM includes administering negative inotropic agents such as beta-adrenergic blocking agents (carvedilol) and calcium antagonists (verapamil). Vasodilators, diuretics, nitrates, and cardiac glycosides are contraindicated in patients with obstructive HCM. Strenuous exercise is also prohibited. Echocardiography, radionuclide imaging, and angiocardiography during cardiac catheterization are performed to diagnose and differentiate cardiomyopathies. The CardioMEMS™ device is used with clients who have heart failure.

28. After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. "I'll read the nutritional labels on food items for salt content." b. "I will drink at least 3 L of water each day." c. "Using salt in moderation will reduce the workload of my heart." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake." f. "Salt substitutes are a good way to cut down on sodium in my diet."

ANS: A, D, E Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client would be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day. Salt substitutes typically contain potassium, so although they are not strictly banned, clients would have to have their renal function and serum potassium monitored while using them. It would be safer to avoid them.

22. A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? a. "Walk until you become short of breath, and then walk back home." b. "Begin walking 200 feet a day three times a week." c. "Do not lift heavy weights for 6 months." d. "Eat plenty of protein to build your strength."

ANS: B A client who has heart failure would be taught to conserve energy and given an exercise plan. The client should begin walking 200-400 feet a day at home three times a week. The client should not walk until becoming short of breath because he or she may not make it back home. The lifting restriction is specifically for clients after valve replacements. Protein does help build strength, but this direction is not specific to heart failure.

24. A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

ANS: B Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.

3. A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."

ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

14. After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? a. "I'll be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by my dentist in 2 weeks." c. "I must avoid eating foods high in vitamin K, like spinach." d. "I must use an electric razor instead of a straight razor to shave."

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy would be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open-heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

18. A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."

ANS: B Clients who have had heart transplants must take immunosuppressant therapy for the rest of their lives. The nurse would teach this client to avoid crowds and sick people to reduce the risk of becoming ill him- or herself. These medications do not place clients at risk for bleeding, orthostatic hypotension, or changes in heart rate. Orthostatic hypotension from the denervated heart is generally only a problem in the immediate postoperative period.

13. A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.

16. A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? a. Heart rate that speeds up and slows down. b. Friction rub at the left lower sternal border. c. Presence of a regular gallop rhythm. d. Coarse crackles in bilateral lung bases.

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related

30. A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about energy conservation techniques. b. Ensure that the client is prescribed a beta blocker. c. Document a discussion about advanced directives. d. Confirm that a postdischarge nurse visit has been scheduled. e. Consult a social worker for additional resources. f. Care transition record transmitted to next level of care within 7 days of discharge.

ANS: B, C, D, F National quality measures aim to decrease heart failure readmission by proper preparation for discharge. These measures include :(1) beta blocker prescribed for left ventricular dysfunction at discharge, (2) postdischarge follow-up appointment scheduled within 7 days of discharge with documentation of location, date, and time. (3) care transition record transmitted to next level of care within 7 days of discharge. (4) documentation of discussion of advance directives/advance care planning with a health care provider, (5) documentation of execution of advance directives within the medical record, and (6) postdischarge evaluation of patient for symptom assessment and treatment adherence within 72 hours of discharge (this can occur by phone, scheduled office visit, or home visit).

17. After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." b. "Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." d. "While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up."

ANS: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client's question.

2. A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I have been drinking more water than usual." b. "I am awakened by the need to urinate at night." c. "I must stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

10. A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? a. "Avoid drinking more than 3 quarts (3 L) of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client would be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

23. A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement? a. Apply an ice pack to the client's chest. b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on.

ANS: D Pain from acute pericarditis may worsen when the client lays supine. The nurse would position the client in a comfortable position, which usually is upright and leaning slightly forward. An ice pack and neck rub will not relieve this pain. Dimming the lights will also not help the pain

19. A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? a. "Would you like to speak with a priest or chaplain?" b. "I will arrange for a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though the concerns are not valid. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the client's concerns instead of immediately calling for the chaplain or psychiatrist. The nurse would not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option.

8. A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take? a. Initiate oxygen therapy. b. Hold the next dose. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

ANS: D The vasodilating effects of nitrates frequently cause clients to have headaches during the initial period of therapy. The nurse would inform the client about this side effect and offer a mild analgesic, such as acetaminophen. The client's headache is not related to hypoxia or dehydration; therefore, applying oxygen and drinking water would not help. The client needs to take the medication as prescribed to prevent angina; the medication would not be held.

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."

B

The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What complication will the nurse suspect? A. Pulmonary embolus B. Renal infarction C. Transient ischemic attack D. Splenic infarction

B

A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop

B, C, E, F

2. The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4 L. C. Place the client in a high-Fowler position. D. Draw arterial blood for arterial blood gas analysis.

C

A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching? A. "I need to brush my teeth at least twice daily and rinse with water." B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." C. "I need to take a full course of antibiotics prior to my colonoscopy." D. "I will take my blood pressure every day and call if it is too high or low."

C