ATI Heart Failure Questions

The RN is teaching a student on the care of a PT who is receiving hemodynamic monitoring. Which statement indicates teaching was effective? 1. Air should be instilled into the monitoring system 2. The client should be in the prone position 3. The transducer should be level with the 2nd intercostal space 4. A chest X-ray is needed to verify placement.

4. A chest X-ray is needed to verify placement.

What are complications of Heart failure?

Pulmonary edema Cardiogenic shock Cardiac tamponade

A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin per day. which of the following is an appropriate response by the nurse? 1. "Aspirin reduces the formation of blood clots that could cause a heart attack." 2. "Aspirin relieves the pain due to MI." 3. "Aspirin dissolves clots that are forming in your coronary arteries." 4. "Aspirin relieves headaches that are caused by other medications."

1. "Aspirin reduces the formation of blood clots that could cause a heart attack."

What is some expected assessment findings of cariogenic shock? Select All 1. tachycardia 2. hypotension 3.crackles 4. angina 5. cool and clammy skin

ALL OF THEM**Cardiogenic shock- complication of pump failure that occurs commonly after MI and injury greater than 40% to the left ventricle. - treat with vasopressors and interpose (digoxin) to increase CO to maintain organ perfusion

A nurse is assessing a client who has left-sided heart failure with decreased cardiac output. Which of the following manifestations should the nurse expect? Flushing of the skin on exertion Nocturia at night Warm lower extremities Respiratory rate of 16/min

Nocturia at night Flushing of the skin on exertion The client who has left-sided heart failure with decreased cardiac output will appear pale in color on exertion due to poor tissue perfusion. Nocturia at night The client who has left-sided heart failure with decreased cardiac output can have oliguria during the day and nocturia at night due to poor tissue perfusion to the kidneys. Warm lower extremities The client who has left-sided heart failure with decreased cardiac output will have cool extremities due to poor tissue perfusion. Respiratory rate of 16/min The client who has left-sided heart failure with decreased cardiac output will have tachypnea due to intra-alveolar fluid causing engorgement of pulmonary vessels.

What part of the ECG would you look for atrial depolarization?

P wave - atrial depolarization QRS- vetricular depolarization T- Ventricular reploarization

Right sided Heart failure results in peripheral edema? TRUE OR FALSE

TRUE**Right side Heart failure results in inadequate right ventricle output and systemic congestion (peripheral edema)

You are caring for a PT receiving hemodynamic monitoring and has the following readings: PAS 34, PAD 21, PAWP 16, CVP 12. which is the PT at risk for? Select All 1. Heart failure 2. Cor pulmonale 3. Hypovolemic shock 4. Pulmonary hypertension 5. Peripheral edema

1. Heart failure-r/t left ventricular failure=high hemodynamic readings 2. Cor pulmonale r/t right side of heart/pulmonary problems= high readings 4. Pulmonary hypertension- would present with high readings 5. Peripheral edema - would indicate left ventricular failure r/t high readings

You are planning a presentation about HTN which lifestyle modifications would you include? Select All 1. Limit alcohol intake 2. Regular exercise program 3. Decreased mag intake 4. Reduced K intake 5. Smoking cessation

1. Limit alcohol intake- Should limit if HTN 2. Regular exercise program- will reduce HTN 5. Smoking cessation- exacerbates HTN

You are caring for a group of PTs and should recognize which PT is at risk for a dysrhythmia? Select All 1. PT with metabolic acidosis 2. PT with K level of 4.3 3. PT whose O2 sat is 96% 4. COPD PT 5. PT who underwent a stent replacement

1. PT with metabolic acidosis-acid base imbalance = @ risk 4. COPD PT- at risk 5. PT who underwent a stent replacement- at risk

You are caring for PT with heart failure and Pt asks how should he limit his fluid to 2000ml/day. What is the best response? 1. Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink 2. Each glass contains 8 oz there are 30ml per oz so you can have a total of 8 glasses a day 3. the is the same as 2 quarts or about the same as two pots of coffee 4. Take sips of water or ice chips so you will not take too much fluid

1. Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink- provides a visual

You are providing teaching to a PT with HF you would instruct him to report what finding? 1. Weight gain of 2lbs in 24hr 2. Increase in 10mmhg in Systolic BP 3. Dyspnea with exertion 4. Dizziness when rising quickly

1. Weight gain of 2lbs in 24hr- fluid retention r/t worsen HF

A nurse is caring for a client who has severe PAD. The nurse should expect that the client will sleep most comfortably in which of the following positions? 1. With the affected limb hanging from the bed 2. With the affected limb elevated on pillows 3. With the head of the bed raised 4. In a side-lying, recumbent position

1. With the affected limb hanging from the bed-dependent position will relieve pain

Which of these are expected findings of pulmonary edema? Select all 1.Tachypnea 2.Persistent cough 3.Increase urinary output 4.Thick yellow sputum 5.Orthopnea

1.Tachypnea- expected 2.Persistent cough-will be frothy pink and indicates pulm. edema 5.Orthopnea- Expected **3.Increase UOP- would be decreased 4.Thick yellow sputum- would be pink and frothy sputum

You are caring for PT with heart failure and reports increased SOB you increase O2 per protocol. What action do you do next? 1. Obtain weight 2.Assist client to high fowlers 3. Auscultate lung sounds 4. Check O2 sat with pulse ox.

2. Assist client to high fowlers- ABCs will decrease venous return to the heart(preload) and help relieve lung congestion

You are caring for a PT after CABG hemodynamic monitoring has been initiated what action would facilitate correct monitoring readings? Select all 1. Place the PT in high Fowlers 2. Level transducer to phlebostatic axis 3. Zero Transducer to room air 4. Observe trends in readings 5. compare readings to physical assessment.

2. Level transducer to phlebostatic axis 3. Zero Transducer to room air 4. Observe trends in readings 5. compare readings to physical assessment.

You are caring for a PT who is being treated for HF and has prescriptions for digoxin and furosemide. You plan to monitor for which of the following as an adverse effect of these meds? 1. SOB 2. Lightheadedness 3. Dry cough 4. Metallic taste

2. Lightheadedness- can cause a sudden drop in BP= lightheadedness

You are providing teaching to a group of PTs which of the Pts is at risk for developing PAD? 1. PT with hypothroidism 2. PT with Diabetes Mellitus 3. PT whose daily diet consists of 25% fat 4. Pt who consumes 2 bottles of beer a day

2. PT with Diabetes Mellitus-at risk for microvascular and progressive peripheral arterial disease

PT is prescribed an ace inhibitor. the RN knows the Pt understands the adverse effects when he reports the following? 1. tendon pain 2. Persistent cough 3. Frequent urination 4. constipation

2. Persistent cough - adverse effect of these meds

PT is prescribed an ace inhibitor. the RN knows the Pt understands the adverse effects when he reports the following? 1. tendon pain 2. Persistent cough 3. Frequent urination 4. constipation

2. Persistent cough- adverse effect of this drug

You are assessing a PT with Left sided heart failure. What manifestation should you expect to find? 1. Increased abdominal girth 2. Weak peripheral pulses 3. Jugular venous neck distention 4. Dependent edema

2. Weak peripheral pulses- r/t decreased CO from LSHF

You are assessing a PT with Left sided heart failure. What manifestation should you expect to find?1. Increased abdominal girth2. Weak peripheral pulses3. Jugular venous neck distention4. Dependent edema

2. Weak peripheral pulses- r/t decreased CO from LSHF

You are reviewing the lab results of several PTs who have PAD. You plan to provide dietary teaching for the PT with which of the following? 1. Cholesterol 180mg, HDL 70mg, LDL 90mg 2.Cholesterol 185mg, HDL 50mg, LDL 120mg 3.Cholesterol 190mg, HDL 25mg, LDL 160mg 4.Cholesterol 195mg, HDL 55mg, LDL 125mg

3. Cholesterol 190mg, HDL 25mg, LDL 160mg** cholesterol should be less than 200HDL above 40LDL less than 100

You are caring for a patient who is scheduled for a CABG in 2hr. Which PT statement needs further clarification? 1. My arthritis is really bothering me b/c i haven't taken my aspirin in a week 2. My BP shouldn't be high b/c i took my BPmeds this morning 3. I took my warfarin last night according to my schedule. 4. I will check my blood sugar b/c i took a reduced dose of insulin this morning

3. I took my warfarin last night according to my schedule.- should have stopped 5-7 days prior for bleeding

You are teaching a PT the importance of remaining still following angiography. Which statement is the best to say? 1. Moving in bed raises your BP 2. Too much activity increases your risk for infection. 3. moving in bed increases your risk of a complication due to anesthesia 4. too much activity places you at risk for bleeding

4. too much activity places you at risk for bleeding