Nursing Med Sur II 1st examn
A nurse is caring for an adult Client who has left sided heart failure. Which of the following assessments findings should the nurse expect? a. Frothy sputum b. Dependent edema c. nocturnal polyuria d. jugular distention
A a. Left sided heart failure reduces cardiac output and rises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue and weakness b. Right sided failure has greater systemic effects because of increased venous pressures and congestion. Manifestations include dependent edema to the extremities and sacrum, enlarged liver and spleen, and ascites c. Nocturnal polyuria indicates right sided heart failure d. jugular distension indicates right sided heart failure. The client might be hypertensive due to the excessive fluid volume
A nurse is preparing to administer a transfusion of RBCs to a client who has a heart failure. For which of the following manifestations should the nurse monitor the to prevent fluid volume overload? (Select all that apply) a. Dyspnea b. gastrointestinal bloating c. jugular vein distention d. confusion e. hypotension
A,C and D a. Dyspnea is correct. dyspnea is a clinical manifestation of fluid volume overload b. gastrointestinal bloating is incorrect. gastrointestinal bloating is not a clinical manifestation of a heart failure c. jugular vein distention is correct. jugular vein distention is a clinical manifestation of fluid volume overload d. confusion is correct. confusion is a clinical manifestation of fluid volume overload e. hypotension as incorrect. Hypertension, Not hypotension is a clinical manifestation of fluid volume overload. Hypertension is a manifestation of a hemolytic transfusion reaction
A nurse in a cardiac care unit is caring for a client with acute right sided heart failure. Which of the following findings should the nurse suspect? a. decrease brain NATRIURETIC peptide (BNP) b. elevated central venous pressure (CVP) c. increased pulmonary artery wedge pressure (PAWP) d. Decrease a specific gravity
B a. The BMP is a neural hormone that aids in the regulation of fluid balance by detecting increased stretch of the myocardium and triggering diuresis through sodium excretion by the kidneys. The BMP level is elevated on the client who has acute heart failure b. CVP is a measurement of the pressure and the right Atria or ventricle at the end of the diastole. An elevated CVP is an indicative of heart failure c. Pulmonary pressure increases in left sided heart failure because of the increased pressure and volume of blood on the left ventricle d. during area specific gravity is increase and decline who has heart failure as a result of fluid retention by the body
A nurse is assessing a client who has left sided heart failure, which of the following findings should the nurse suspect? a. Jugular venous distention b. abdominal distention c. dependent edema d. hacking cough
D a. Right sided heart failure raises the pressure and volume within the jugular veins, making them visible the standard when the client is sitting, or the head of the bed as elevated more than 30 degrees b. abdominal distension is a manifestation of right sided heart failure that occurs due to venous congestion c. dependent edema is a manifestation of right sided heart failure pressing edematous skin with a finger leaves a transient indentation (pitting) d. A hacking cough is a manifestation of left sided heart failure that occurs due to pulmonary congestion
A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? a. Morphine sulfate 2mg IV bolus every 2hr PRN for pain b. Laboratory testing of serum potassium upon admission c. 0.9% Normal saline IV at 50 ml/hr. continuous. d. Bumetanide 1mg IV bolus every 12hr.
C a. Morphine sulfate is given to clients with acute heart failure to reduce anxiety, decrease cardiac preload and afterload, is slow respirations, and manage pain associated with MI. This prescription does not require clarification. b. serum potassium is monitor due to the use of diuretic therapy in a client with acute heart failure. This prescription does not require clarification. c. 0.9% sodium chloride is isotonic and will not cause the fluid shift needed in this client to reduce circulatory overload. This prescription requires clarification d. BUMETANIDE, end loop diuretic is given as first line drug of choice for the client in acute heart failure. This prescription does not require clarification
the nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply) a. Increased heart rate b. increased blood pressure c. increases respiratory rate d. increase hematocrit e. increase temperature
"A, B and C" a) Increase heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increase cardiac contractility in response to the excess fluid b) increase blood pressure is correct. the nurse should expect the client who has fluid volume access to have increased blood pressure and bounding pulse in response to excess fluid c) increase respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs. d) increase hematocrit is incorrect the nurse should expect the client who has fluid volume deficit to have an elevated hematocrit because of hemoconcentration. e) increase temperature as incorrect. The nurse should expect the client who has fluid volume deficit to have an increase in temperature due to fluid loss
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? a. Analgesic b. Anti- inflammatory c. Antiplatelet aggregate d. Anti-pyretic
"C" a. Although aspirin does have an analgesic effect, cardiac clients who take 325 milligrams daily are taking it for a different purpose b. Although aspirin does have an analgesic effect, cardiac clients who take 325 milligrams daily are taking it for a different purpose c. Aspirin is used to decrease the like hood of blood clotting, it is also used to reduce the risk of a second heart attack or a stroke by inhibiting platelet aggregation and reduction thrombus formation in an artery, a vein, or heart. d. Although aspirin does have an analgesic effect, cardiac clients who take 325 milligrams daily are taking it for a different purpose
A nurse is plaining to administer digoxin to a client who has heart failure. Which of the following lab results as the priority for the nurse to review prior to administering the medication? a. Potassium b. Hemoglobin c. Creatinine d. BUN
A a. Digoxin is a cardiac glycoside medication used to improve myocardial contractility. Increasing stroke volume in cardiac output in a client who has heart failure, during therapy the nurse should closely monitor the client's potassium levels as hypokalemia increases the risk of digitalis toxicity and cardiac arrhythmias b. Digoxin is a cardiac glycoside used to increase the force of myocardial contraction and decreases heart rate declines hemoglobin level should be monitored but there is another lab value that is a priority c. Creatinine is monitored to identify renal impairment and indicate the glomerular filtration rate. Digoxin is a cardiac glycoside used to increase cardiac output and a client who has heart failure. The client's creatine level should be monitored but there is another lab value that is a priority d. BUN S form and deliver us a metabolite of protein. BUM increases with compromise kidney filtration. High protein diet, fever, and dehydration. Bunn creatinine levels are monitored together when caring for a client who has renal failure. The client's BUN level should be monitored but there is another lab value there is a priority
A nurse is monitoring the cardiac output of a client who has left sided heart failure using pulse pressure analysis. Which of the following findings can compromise the readings? a. the client is experiencing premature atrial contractions b. the client has a decreased oxygen saturation level c. decline has bilateral wheezes d. the client has lower leg edema.
A a. Pulse pressure devices require the presence of optimal arterial waveforms, in order to capture accurate data. Therefore, dysrhythmia such a premature atrial contraction will compromise the readings b. Decrease oxygen saturations as a manifestation of a heart failure that does not compromise cardiac output readings c. bilateral wises are a manifestation of a heart failure that do not compromise cardiac output readings d. lower leg edema is a manifestation of a heart failure that does not compromise cardiac output readings
A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness. Dyspnea at rest, crackles, blood pressure 110/79 mm Hg, apical heart rate 112/min per. Which of the following interventions is the nurse's priority? a. Provide the client with supplemental oxygen at 5 liters per minute by face mask b. place the client in high fowlers position with their leg and independent position c. gives the client sublingual nitroglycerin d. administers morphine sulfate IV
A a. The first action the nurse should take when using the airway, breathing, and circulation approach to the client care is to provide supplemental oxygen at 5 liters by simple face masks to promote effective gas exchange and tissue perfusion and to prevent rebreathing of excelled air. The client is exhibiting signs of respiratory distress, such as dyspnea at rest, crackles. Therefore, this is the nurse's priority intervention because it will help manage hypoxia related to pulmonary edema b. The nurse should place the client in high fowlers position with their legs in a dependent position to decrease venous blood return to the heart. However, there is another intervention that is the nurse's priority. c. The nurse should give the clients of lingual nitroglycerin to decrease the preload and afterload. However, there is another intervention that is the nurse's priority. d. the nurse should administer morphine sulfate IV to decrease the preload and afterload and decrease the client's anxiety. However, there is another intervention that is the nurse's priority
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching? a. Exercise at least three times a week b. take diuretics early in the morning and before bedtime c. notify the provider of a weight gain of 0.5 kilograms (1 lb.) In a week d. take naproxen for generalized discomfort
A a. The nurse encourages the client to stay as active as possible on to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The clients should try to walk at least three times per week and should slowly increase the amount of time walk over several months. Regular exercise strengthens the heart and cardiovascular system, therefore improving circulation and lowering blood pressure b. A client who is taking diuretics should take them in the early morning and early afternoon. The nurse instructs the client not to take the diuretics nearby bedtime to avoid sleep pattern disturbance secondary to increase urination. c. The nurse should instruct the client to check weight daily at the same time and notify the provider of a weight gain of 1.4 to 2.3 kilograms (3-5lbs) in one week or 0.5 to 1 kilogram (1-2Lb) overnight the client should be instructed that excessive weight gain indicates fluid volume excess and fluid retention. d. The nurse should instruct the client to avoid the use of NSAIDs as they contribute to sodium and fluid retention worsening the client's condition
a nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following clients' statements indicates to the nurse that the teaching was effective? a. "I will read food labels and limit my sodium to 4 grams per day" b. "I should use naproxen to manage discomfort" c. "I plan to slow down if I am tired the day after exercising" d. "I will take my diuretic before sleep and drink fluids during the day"
C a. Although it is especially important for clients who have heart failure to read the labels of food items in order to avoid large amounts of sodium, the nurse should instruct the client to consume no more than two grams of sodium per day. Excessive sodium intake increases fluid retention and the workload on the heart b. a client who has heart failure should avoid the use of NSAIDs as these medications can cause sodium retention. The nurse should recommend the use of acetaminophen for the treatment of discomfort c. clients who experience chest pain or dyspnea while exercising or experience fatigue the next day are probably advancing the activity too quickly and should slow down d. Diuretics are used in the treatment of heart failure to remove excess extracellular fluid from the body. Client should be advised to take diuretics in the morning to avoid waking during the night for voiding. If the client as prescribed fluid restrictions, the nurse should assist him in planning fluid intake during the day
A nurse is caring for a client who has a valvular heart disease and is at risk for developing left side heart failure. which of the following manifestations should the nurse the client is developing this condition? a. Anorexia b. weight gain c. shortness of breath d. abdominal distention
C a. Anorexia and Nausea are manifestations of right sided heart failure b. weight gain resulting from edema and ascites is a manifestation of right sided heart failure c. manifestations of left sided heart failure include crackles or whistles and breathlessness due to pulmonary congestion d. it is standard abdomen is a manifestation of right sided heart failure
A nurse is caring for a client who has heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering for furosemide? a. Bicarbonate b. carbon dioxide c. potassium d. phosphate
C a. The nurse should check the clients' electrolytes and other labs results before initiating diuretic therapy however furosemide does not generally affect bicarbonate levels b. The nurse should check the clients' electrolytes and other laboratory results before initiating diuretic therapy however for furosemide does not generally affect carbon dioxide levels c. Furosemide is a loop diuretic and therefore promotes excretion of potassium. The nurse should monitor the client's serum potassium levels before administering it to prevent hypokalemia d. the nurse should check the clients' electrolytes and other laboratory results before initiating diuretic therapy however furosemide does not generally affect phosphate levels.