chapter 37 med/surg

The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level?

"Are you able to walk upstairs without fatigue?"

A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client's discharge instructions?

"Avoid large crowds and people who are sick."

A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client?

"Avoid using salt substitutes."

A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse's best response?

"Blood clots form more easily in artificial replacement valves."

The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client?

"Do not take this medication within 1 hour of taking an antacid."

The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction?

"Gather everything you need for a chore before you begin."

The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure?

"I have to stop halfway up the stairs to catch my breath."

The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education?

"I will have my teeth cleaned by the dentist in 2 weeks."

The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure?

"My shoes fit really tight lately."

A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client?

"Please come into the clinic for an evaluation."

A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure?

"Weigh yourself daily while wearing the same amount of clothing."

A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response?

"Weight is the best indication that you are gaining or losing fluid."

A client with end-stage heart failure 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." What is the nurse's best response?

"Would you like information about advance directives?"

An older adult client with heart failure 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 nurse's best response?

"Would you like to talk about this more?"

The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include?

"You should report episodes of dizziness or fainting."

The client who just started taking isosorbide dinitrate (Imdur) reports a headache. What is the nurse's best action?

Administer PRN acetaminophen.

A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action?

Administer loop diuretics as prescribed.

A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action?

Administer the Vasotec.

A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect?

An increase in heart rate and respiratory rate

The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's best intervention?

Assess for symptoms of left-sided heart failure.

A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention?

Assess respiratory status.

The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication?

Confusion

A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change?

Decrease in tissue perfusion

The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client's stenosis has progressed?

Dyspnea on exertion

An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority?

Echocardiography

A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client?

Friction rub at the left lower sternal border

The nurse is caring for a client with severe heart failure. What is the best position in which to place this client?

High Fowler's, pillows under arms

The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about?

History of a systemic infection within the past month

A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication?

Insert a separate IV access.

The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client?

Instruct the client to ask for assistance when arising from bed.

The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure?

Middle-aged woman with aortic stenosis

The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention?

Monitor the client's blood pressure.

The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client?

Narrowed pulse pressure

A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action?

Place the client in a high Fowler's position.

A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse?

Potassium of 2.9 mEq/L

The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use?

Standard Precautions

The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity?

Systolic blood pressure change from 136 to 96 mm Hg

The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment?

The heart is hypertrophied.

The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority?

The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes.