Chapter 29: Acute Care

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?

"I sleep on three pillows each night."

A patient has missed 2 doses of digitalis. What laboratory results would indicate to the nurse that the patient is within therapeutic range?

2.0 mg/mL

A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be?

30%

A client has had an echocardiogram to measure ejection fracton. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?

55

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

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.

The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse?

Call for help and begin chest compressions.

A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next?

Check the client's potassium level.

The nurse identifies which symptom as a manifestation of right-sided heart failure (HF)?

Congestion in the peripheral tissues

A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved?

Decrease in central venous pressure (CVP)

Which medication reverses digitalis toxicity?

Digoxin immune FAB

A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure?

Hypertension causes the heart's chambers to enlarge and weaken.

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV

A client in the hospital informs the nurse he "feels like his heart is racing and can't catch his breath." What does the nurse understand occurs as a result of a tachydysrhythmia?

It reduces ventricular ejection volume.

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?

JVD is noted 4 cm above the sternal angle.

Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?

Monitor blood pressure frequently

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?

Spironolactone

What is the main difference between Class I and Class II heart failure as defined by the New York Heart Association (NYHA)?

The level of physical activity each allows

Which is a classic sign of cardiogenic shock?

Tissue hypoperfusion

A client with a history of heart failure is returning from the operating room after inguinal hernia repair and the nurse assesses a low pulse oximetry reading. What is the most important nursing intervention?

Titrate oxygen therapy.

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

A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:

canned peas.

A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)?

decrease in renal perfusion

The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema?

decreased left ventricular pumping

Frequently, what is the earliest symptom of left-sided heart failure?

dyspnea on exertion

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?

echocardiogram

The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure?

furosemide

The nurse is assessing a newly admitted client with chest pain. What medical disorder is most likely causing the client to have jugular vein distention?

heart failure

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what action should the nurse perform?

high fowlers

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival?

lisinopril

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?

nausea and vomiting

The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity?

potassium level of 2.8 mEq/L

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?

preload

A nurse suspects that a client has digoxin toxicity. The nurse should assess for:

vision changes

A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?

weight

A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action?

Administer epinephrine.

The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg?

Administer the third sublingual nitroglycerin tablet.

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.

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered?

An echocardiogram

The nurse is teaching a group of clients with heart failure about how to decrease leg edema. What dietary advice will the nurse give to clients with severe heart failure?

Avoid the intake of processed and commercially prepared foods.

A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?

Blood pressure 80/46 mm Hg

Which is a key diagnostic indicator of heart failure?

Brain natriuretic peptide (BNP)

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)

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Echocardiogram

The nurse is teaching a client about lifestyle modifications after a heart failure diagnosis. What will be included in the teaching?

Engage in exercise daily.

A nurse finds a client with absent breathing and prepares to begin one-person cardiopulmonary resuscitation. What will the nurse do first?

Establish unresponsiveness.

A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply.

Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion.

A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence?

Excess pericardial fluid compresses the heart and prevents adequate diastolic filling.

The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience?

Gradual unexplained weight gain

A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload?

Head of the bed elevated 45 degrees and lower arms supported by pillows

Which is a characteristic of right-sided heart failure?

Jugular vein distention

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 function

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 feature is the hallmark of systolic heart failure?

Low ejection fraction (EF)

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate?

Morphine sulfate

A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of

PE

The client with cardiac failure is taught to report which symptom to the physician or clinic immediately?

Persistent cough

A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure?

Right-sided heart failure

Which is a manifestation of right-sided heart failure?

Systemic venous congestion

Assessment of a client on a medical surgical unit finds a regular heart rate of 120 beats per minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 mL over the past hour. What is the reason the nurse anticipates transferring the client to the intensive care unit?

The client is going into cardiogenic shock.

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?

The development of left-sided heart failure

A client taking an ACE inhibitor has developed a dry, hacking cough. Because of this side effect, the client no longer wants to take that medication. What medication that has similar hemodynamic effects does the nurse anticipate the health care provider ordering?

Valsartan

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.

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). How should the nurse document this sound?

a third heart sound (S3).

A client with left-sided heart failure reports 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 what condition?

acute pulmonary edema.

A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing

decompensated heart failure with pulmonary edema.

The nurse is providing care to a client with cardiogenic shock requring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy?

decreased left ventricular workload

Which is a cerebrovascular manifestation of heart failure?

dizzines

The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart?

echocardiogram

The nurse is asssessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion?

inadequate cardiac output

Which is the hallmark of heart failure?

low EF

A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?

mask

The nurse is caring for a client with heart failure who is receiving torsemide. What implementation will help the nurse evaluate the client's response of the medication?

measuring intake and output

When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating

orthopnea.

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective?

peripheral edema

The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure?

pitting edema

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." What additional assessment information would be important for the CSU nurse to obtain?

pulmonary crackles

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.)

pulmonary crackles dyspnea cough