medsurg exam 2

A 50-year-old woman weighs 95 kg and has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are a.weight and diet. b.activity level and diet. c.tobacco use and high blood pressure. d.sedentary lifestyle and high blood pressure.

c

A 57-year-old client with a history of asthma is prescribed propranolol (Inderal) to control hypertension. Before administered propranolol, which of the following actions should the nurse take first? A. Monitor the apical pulse rate B. Instruct the client to take medication with food C. Question the physician about the order D. Caution the client to rise slowly when standing

c

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these actions included in the standard TEE orders will the nurse need to accomplish first? a. Administer O2 per mask. b. Start a large-gauge IV line. c. Place the patient on NPO status. d. Give lorazepam (Ativan) 1 mg IV.

c

Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility? A. Beta-adrenergic blockers B. Calcium channel blockers C. Diuretics D. Inotropic agents

d

Which of the following information should be given to a patient before taking hydrochlorothiazide for control of hypertension? A. "You can develop a slower pulse rate." B. "You might notice some swelling in your feet." C. "You can develop shortness of breath or a cough." D. "Your diet should include foods high in potassium."

d

Which of the following is a compensatory response to decreased cardiac output? a. Decreased BP b. Decreased BP and diuresis c. Alteration in LOC d. Increased BP and fluid retention

d

Which of the following is a potential side effect of IV furosemide (Lasix)? A. drowsiness B. diarrhea C. cystitis D. hearing loss

d

digoxin therapeutic level

0.5-2

The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned about a. an apical pulse rate of 106 beats/min. b. an oxygen saturation of 88% on room air. c. weight gain of 1 kg (2.2 lb) over 24 hours. d. decreased hourly patient urinary output.

B Rationale: A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.

The client is prescribed digoxin (Lanoxin) for treatment of HR. Which of the following statements by the client indicates the need for further teaching by the nurse? A. "I should not get short of breath anymore." B "This drug will help my heart muscle pump less." C. "I may notice my heart rate decrease." D. "I may feel tired during early treatment."

B Rationale: The ability to increase the strength of contractions is a characteristic of cardiac glycosides. It may result in a decrease in pulse. Initially the client may experience some fatigue. Symptoms of CHF, such as dyspnea, should improve.

While admitting an 80-year-old patient with heart failure to the medical unit, the nurse obtains the information that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." The nurse makes a note that discharge planning for the patient will need to include a. transfer to a dementia care service. b. referral to a home health care agency. c. placement in a long-term-care facility. d. arrangements for around-the-clock care.

B rationale: A home health nurse will assess the patient's home situation and help the patient to develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term-care, or around-the-clock home care.

With which of the following disorders is jugular vein distention most prominent? A. Abdominal aortic aneurysm B. Heart failure C. Myocardial infarction D. Pneumothorax

B rationale: Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump.

During the cardiac assessment, the nurse finds a client has jugular vein distention. What does this mean to the nurse? a. The client is fine. b. The client is dehydrated .c. The client has an infection. d. The client could have fluid overload

D

A nurse is monitoring the digoxin level for a client who has been taking a daily dose of digoxin for 1 month. the digoxin level is 0.25 ng/mL. The nurse should notify the provider and anticipate which of the following: 1. An increase in the client's digoxin dose. 2. A decrease in the client's digoxin dose. 3. No change in the client's digoxin dose. 4. Dicontinuation of the client's digoxin dose.

a

A pt has a potassium level of 6.0 and a digoxin level of 3.0. What medication would the nurse be giving: A. digibind B. sodium citrate C. epinephrine D. lidocaine

a

Toxicity from which of the following medications may cause a client to see a green halo around lights? A. Digoxin B. Furosemide C. Metoprolol D. Enalapril

a

Which of the following parameters should be checked before administering digoxin? A. Apical pulse B. Blood pressure C. Radial pulse D. Respiratory rate

a rationale: An apical pulse is essential or accurately assessing the client's heart rate before administering digoxin. The apical pulse is the most accurate point in the body.

All potassium-sparing diuretics: A. are required during blood transfusions B. enhance aldosterone action C. cause hypokalemia D. are weak diuretics

b

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to ADHF? a. Take medications as prescribed. b. Use oxygen when feeling short of breath. c. Only ask the physician's office questions. d. Encourage most activity in the morning when rested.

a rationale: The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF.

What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with heart failure? a. Acute anxiety b. Hypotension and tachycardia c. Peripheral edema and weight gain d. Paroxysmal nocturnal dyspnea (PND)

b rationale: Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

Patients with a heart transplantation are at risk for which complications in the first year after transplantation (select all that apply)? a. cancer b. infection c. rejection d. vasculopathy e. sudden cardiac death

b, c, e

A pt is taking digoxin and furosemide (Lasix) to manage congestive heart failure. The nurse determiens that the pt understands diet therapy when the pt makes which meal choice? A. veggie beef soup, mac and cheese, and a roll B. beef ravioli w/ bread C. baked white fish, mashed potatoes, and carrot salad D. roasted chicken, brown rice, and stewed tomatoes

c

If a patient who has experienced an MI develops left ventricular heart failure, for what sign of poor organ perfusion should a nurse remain alert? A. Headache B. Hypertension C. Heart rate of 55 to 60 beats/min D. Urine output of less than 30 ml/hour

d

Nurse Margie just administered an ACE inhibitor to her pt. Before ambulating the pt for the first time after administration, the nurse should monitor for: A. hypokalemia B. irregular heartbeat C. edema D. hypotension

d

A nurse is administering a dopamine infusion at a moderate dose to a client who has severe HF. Which of the following is an expected effect? 1. Lowered heart rate 2. Increased myocardial contractility 3. Decreased conduction through the AV node D. Vasoconstriction of the renal blood vessels

2 rationale: increasing myocardial contractility increases the cardiac output

A nurse provides discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching? 1. "I will take my pills every day at the same time." 2. "I will avoid alcohol consumption." 3. "I have already called my family to pick up a Medic-Alert bracelet." 4. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."

4

Which of the following is a contraindication for digoxin administration? A. BP of 140/90 B. HR>80 C. HR<60 D. RR>18

c

What is the leading cause of PAD? a) smoking b) hyperlipidemia c) hypertension d) atherosclerosis

d

Intravenous heparin therapy is prescribed for a client. While implementing this prescription, a nurse ensures that which of the following medications is available on the nursing unit? 1. Protamine sulfate 2. Potassium chloride 3. Aminocaproic acid (Amicar) 4. Vitamin K (AquaMEPHYTON)

1

A nurse is providing teaching to a client who has a new prescription for digoxin (Lanoxin) Which of the following may indicate dig toxicity & should be reported to the provider? 1. Fatigue 2. constipation 3. Anorexia 4. Rash 5. Diplopia

1, 3, 5 rationale: 1. FatigueNot constipation but -- nausea, vomiting & diarrhea3. Anorexia b/c GI disturbances5. Diplopia -- visual changes , halo, yellow-tinged vision.

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. The nurse would determine that the client is receiving the therapeutic effect based on which of the following results? 1. Prothrombin time of 12.5 seconds 2. Activated partial thromboplastin time of 60 seconds 3. Activated partial thromboplastin time of 28 seconds 4. Activated partial thromboplastin time longer than 120 seconds

2

A 66-year-old client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include atenolol (Tenormin), digoxin (Lanoxin), and chlorothiazide (Diuril). A tentative diagnosis of digoxin toxicity is made. Which of the following assessment data would support this diagnosis? 1. Dyspnea, edema, and palpitations 2. Chest pain, hypotension, and paresthesia 3. Double vision, loss of appetite, and nausea 4. Constipation, dry mouth, and sleep disorder

3

A home health care nurse is visiting an older client at home. Furosemide (Lasix) is prescribed for the client and the nurse teaches the client about the medication. Which of the following statements, if made by the client, indicates the need for further teaching? 1. "I will sit up slowly before standing each morning." 2. "I will take my medication every morning with breakfast." 3. "I need to drink lots of coffee and tea to keep myself healthy." 4. "I will call my doctor if my ankles swell or my rings get tight."

3

The healthcare provider is performing an assessment on a patient who is taking propranolol (Inderal) for supraventricular tachycardia. Which assessment finding is an indication the patient is experiencing an adverse effect of this drug?Please choose from one of the following options. A. Dry mouth B. Bradycardia C. Urinary retention D. Paresthesia

b

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? a. ADHF b. Chronic HF c. Left-sided HF d. Right-sided HF

d rationale: An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

cardiomyopathy

heart muscle disorder that results in heart enlargement and impaired cardiac contractility

nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the physician and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side-lying position

1, 2, 3, 4 rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

client with HF has an order for lisnopril (Prinivil, Zestril) Which of the following conditions in the client's history would lead a nurse to confirm the order with the provider? 1. A history of HT previously treated with diuretics. 2. A history of seasonal allergies currently treated with antihistamines. 3. A history of angioedema after taking enalapril (Vasotec) 4. A history of alcoholism, currently abstaining.

3

When teaching a patient with peripheral arterial disease, the nurse determines that further teaching is needed when the patient says, 1. "I should not use heating pads to warm my feet." 2. "I will examine my feet every day for any sores or red areas." 3. "I should cut back on my walks if they cause pain in my legs." 4. "I think I can quit smoking with the use of short-term nicotine replacement and support groups."

3 Rationale: Patients should be taught to exercise to the point of discomfort, stop and rest, and then resume walking until the discomfort recurs. Smoking cessation and proper foot care are also important interventions for patients with peripheral arterial disease

An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient a. has BP of 88/42. b. has an apical pulse rate of 56. c. complains of feeling tired d. has 2+ pedal edema.

a Rationale: The patient's BP indicates that the dose of carvedilol may need to be decreased because the mean arterial pressure is only 57. Bradycardia is a frequent adverse effect of -Adrenergic blockade, but the rate of 56 is not as great a concern as the hypotension. -adrenergic blockade will initially worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

Your patient is diagnosed with peripheral arterial disease and asks you what this disease is and what causes it? Which response is most appropriate? a) PAD is the thickening of arterial walls that results in gradual narrowing. This thickening and narrowing is related to arterial wall damage and inflammation. b) PAD is the thinning of arterial walls that results in gradual weakening. This weakening is related to high blood pressure. c) Let me get your doctor to explain this to you. d) PAD is the hardening of the arterial walls that results in thickening and eventual closure of the vessel.

a

Your pt starts showing signs of gynecomastia, which diuretic would you suspect they are on? A. potassium-sparing B. thiazide C. loop D. calcium channel blockers

a

A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse can best document this assessment information as a. pulsus alternans. b. paroxysmal nocturnal dyspnea. c. two-pillow orthopnea. d. acute bilateral pleural effusion.

b Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation.

Which of the following adverse effects is of most concern for the older adult pt taking anti-hypertensive drugs A. dry mouth B. hypotension C. restlessness D. constipation

b

Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? A. Antihypertensive B. Beta-adrenergic blockers C. Calcium channel blockers D. Nitrates

b rationale: By decreasing the heart rate and contractility, beta-adrenergic blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy.

he client is prescribed a beta-blocker as adjunct therapy to treatment of heart failure. The nurse recognizes that beta blockers act by A. Increasing contractility and cardiac output. B. Decreasing preload. C. Slowing the heart and decreasing afterload. D. Decreasing peripheral resistance

c Rationale: Beta-blockers improve symptoms of HF by slowing heart rate and decreasing blood pressure. The decreased afterload causes decreased workload on the heart.

To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review? a. Myoglobin b. Homocysteine (Hcy) c. Low-density lipoprotein (LDL) d. B-type natriuretic peptide (BNP)

d

When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. eggs and other high-cholesterol foods. b. canned and frozen fruits. c. fresh or frozen vegetables. d. milk, yogurt, and other milk products

d Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? a. Muscle aches b. Constipation c. Pounding headache d. Anorexia and nausea

d rationale: Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? a. Infection b. Acute rejection c. Immunosuppression d. Cardiac vasculopathy

d rationale: Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient's risk of an infection.

A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside, what should the nurse assess first? a. Urine output b. Heart rhythm c. Breath sounds d. Blood pressure

d rationale: The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas exchange.

A physical assessment finding that the nurse would expect to be present in the patient with acute left-sided heart failure is A. bubbling crackles and tachycardia. B. hepatosplenomegaly and tachypnea. C. peripheral edema and cool, diaphoretic skin .D. frothy blood-tinged sputum and distended jugular veins.

a

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: a. Alteration in tissue perfusion related to compromised circulation b. Dysfunctional use of extremities related to muscle spasms c. Impaired mobility related to stress associated with pain d. Impairment in muscle use associated with pain on exertion.

a

The client's serum digoxin level is 2.2 ng/dL and the heart rate is 120 and irregular. The nurse expects to administer which of the following drugs? A. Digoxin immune Fab (Digibind) B. Furosemide (Lasix) 60 mg I.V. C. Digoxin 0.5 mg bolus I.V. D. Potassium 40 mEq added to I.V. fluids

a Rationale: Digibind binds and removes digoxin from the body and prevents toxic effects of digoxin overdose. A serum level of 2.2 is elevated, and the client is exhibiting signs of digoxin toxicity. The question does not indicate that the potassium level is low. Giving additional digoxin would exacerbate the toxicity. Giving Lasix may reduce potassium levels and contribute to increased toxicity.

A patient with ADHF who is receiving nesiritide (Natrecor) asks the nurse how the medication will work to help improve the symptoms of dyspnea and orthopnea. The nurse's reply will be based on the information that nesiritide will a. dilate arterial and venous blood vessels, decreasing ventricular preload and afterload. b. improve the ability of the ventricular myocardium to contract, strengthening contractility. c. enhance the speed of impulse conduction through the heart, increasing the heart rate. d. increase calcium sensitivity in vascular smooth muscle, boosting systemic vascular resistance.

a Rationale: Nesiritide, a recombinant form of BNP, causes both arterial and venous vasodilation, leading to reductions in preload and afterload. Inotropic medications, such as dopamine and dobutamine, may be used in ADHF to improve ventricular contractility. Nesiritide does not increase impulse conduction or calcium sensitivity in the heart.

A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to a. auscultate the lung sounds. b. assess the orientation. c. check the capillary refill. d. palpate the abdomen.

a Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority.

Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy? A. Heart failure B. DM C. MI D. Pericardial effusion

a rationale: Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. Myocardial infarction results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with percarditis. Diabetes mellitus is unrelated to cardiomyopathy.

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply)? a. Left ventricular function is documented. b. Controlling dysrhythmias will eliminate HF. c. Prescription for digoxin (Lanoxin) at discharge d. Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge e. Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

a, d, e rationale: The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.

Examination of a patient in a supine position reveals distended jugular veins from the base of the neck to the angle of the jaw. This finding indicates: a. decreased venous return. b. increased central venous pressure. c. increased pulmonary artery capillary pressure. d. left-sided heart failure.

b

When teaching a patient why spironolactone (Aldactone) and furosemide (Lasix) are prescribed together, the nurse bases teaching on the knowledge that: A. Moderate doses of two different types of diuretics are more effective than a large dose of one type B. This combination promotes diuresis but decreases the risk of hypokalemia C. This combination prevents dehydration and hypovolemia D. Using two drugs increases osmolality of plasma and the glomerular filtration rate

b

With peripheral arterial insufficiency, leg pain during rest can be reduced by: a. Elevating the limb above heart level b. Lowering the limb so it is dependent c. Massaging the limb after application of cold compresses d. Placing the limb in a plane horizontal to the body

b

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that begin when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? a. An acute obstruction in the vessels of the legs b. Peripheral vascular problems in both legs c. Diabetes d. Calcium deficiency

b rationale: Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? a. Withhold the daily dose until the following day. b. Withhold the dose and report the potassium level. c. Give the digoxin with a salty snack, such as crackers. d. Give the digoxin with extra fluids to dilute the sodium level.

b rationale: The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

Select all that apply. Which of the following are characteristic manifestations of paroxysmal nocturnal dyspnea (PND)? A. Vomiting B. Nighttime awakening C. Migraine-type headache D. Episodes of snoring accompanied by apnea E. Relief of symptoms when the patient sits upright F. Occurrence 2 to 3 hours after the patient goes to sleep

b, e, f

During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. incompetent jugular vein valves. c. elevated right atrial pressure. d. jugular vein atherosclerosis.

c

If a nurse is teaching foot care to a patient with peripheral vascular disease, which of the following is a correctly written learning objective? A. "The nurse will instruct the patient on appropriate foot care." B. "The nurse will demonstrate to the patient the proper technique for trimming toenails." C. "By discharge, the patient will list three ways to protect the feet from injury." D. "The patient will understand the rationale for proper foot care after instruction

c

One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect? A. Hypocalcemia B. Hypermagnesemia C. Hypokalemia D. Hypernatremia

c

Rest pain is a manifestation of PAD that occurs due to a chronic a. vasospasm of small cutaneous arteries in the feet. b. increase in retrograde venous blood flow in the legs. c. decrease in arterial blood flow to the nerves of the feet. d. decrease in arterial blood flow to the leg muscles duringexercise.

c

During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to venous congestion. b. disturbed body image related to massive leg swelling. c. impaired skin integrity related to peripheral edema. d. impaired gas exchange related to chronic heart failure.

c Rationale: The patient's findings of severe dependent edema and weeping serous fluid from the legs support the nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance, disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate.

The nurse developing a teaching plan for a client receiving thiazide diuretics should include the following. A. Teaching the client to take apical pulse. B. Decreasing potassium-rich foods in the diet. C. Including citrus fruits, melons, and vegetables in the diet. D. Teaching the client to check blood pressure t.i.d.

c Rationale: Thiazide diuretics are potassium wasting, and levels should be closely monitored. Encouraging foods rich in potassium could help maintain potassium levels. Taking an apical pulse is indicated before administering cardiac glycosides and beta blockers. It would not be necessary to check blood pressure TID unless the client was experiencing hypotension.

Septal involvement occurs in which type of cardiomyopathy? A. Congestive B. Dilated C. Hypertrophic D. Restrictive

c rationale: In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum - not the ventricle chambers - is apparent. This abnormality isn't seen in other types of cardiomyopathy.

Which of the following symptoms might a client with right-sided heart failure exhibit? A. Adequate urine output B. Polyuria C. Oliguria D. Polydipsia

c rationale: Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria.

What supplemental medication is most frequently ordered in conjuction with furosemide (Lasix)? A. Chloride B. Digoxin C. Potassium D. Sodium

c rationale: Supplemental potassium is given with furosemide because of the potassium loss that occurs as a result of this diuretic.

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? a. Urine output b. Lung sounds c. Blood pressure d. Respiratory rate

c rationale: priority assessment would be monitoring for hypotension b/c it is the main adverse effect of nesiritide

ou are caring for a patient with ADHF who is receiving IV dobutamine (Dobutrex). You know that this drug is ordered because it (select all that apply): a. incerases SVR b. produces diuresis c. improves contractility d. dilates renal blood vessels e. works on the B1-receptors in the heart.

c, and e Rationale: Dobutamine (Dobutrex) has a positive chronotropic effect and increases heart rate and improves contractility. It is a selective β-adrenergic agonist and works primarily on the β1-adrenergic receptors in the heart. It is frequently used in the short-term management of acute decompensated heart failure (ADHF).

if a patient with heart failure is being treated with digoxin and has developed hypokalemia, the nurse should A. administer digoxin twice daily. B. reduce the digoxin dose to every other day. C. administer an IV bolus of potassium. D. monitor the patient for toxic effects that can occur at normal doses.

d

cardiomyopaathy is usually identiified as a symptom of:

left-sided HF

A nurse is planning to administer hydrochlorothiazide (HydroDIURIL) to a client. The nurse understands that which of the following are concerns related to the administration of this medication? 1. Hypouricemia, hyperkalemia 2. Increased risk of osteoporosis 3. Hypokalemia, hyperglycemia, sulfa allergy 4. Hyperkalemia, hypoglycemia, penicillin allergy

3 rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to a. administer IV morphine sulfate 2 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase dopamine (Intropin) infusion by 2 mcg/kg/min. d. increase nitroglycerin (Tridil) infusion by 5 mcg/min.

a Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output but will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea

Which of the following types of cardiomyopathy can be associated with childbirth? A. Dilated B. Hypertrophic C. Myocarditis D. Restrictive

a rationale: Although the cause isn't entirely known, cardiac dilation and heart failure may develop during the last month of pregnancy of the first few months after birth. The condition may result from a preexisting cardiomyopathy not apparent prior to pregnancy. Hypertrophic cardiomyopathy is an abnormal symmetry of the ventricles that has an unknown etiology but a strong familial tendency. Myocarditis isn't specifically associated with childbirth. Restrictive cardiomyopathy indicates constrictive pericarditis; the underlying cause is usually myocardial.

Which of the following symptoms is most commonly associated with left-sided heart failure? A. Crackles B. Arrhythmias C. Hepatic engorgement D. Hypotension

a rationale: Crackles in the lungs are a classic sign of left-sided heart failure. These sounds are caused by fluid backing up into the pulmonary system. Arrhythmias can be associated with both right and left-sided heart failure. Left-sided heart failure causes hypertension secondary to an increased workload on the system.

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? a. Reduce preload. b. Decrease afterload. c. Increase contractility. d. Promote vasodilation.

a rationale: Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.

A patient with chronic HF and atrial fibrillation is treated with a digitalis glycoside and a loop diuretic. To prevent possible complications of this combination of drugs, what does the nurse need to do (select all that apply)? a. Monitor serum potassium levels b. teach the patient how to take a pulse rate. c. keep an accurate measure of intake and output d. Teach the patient about dietary restriction or potassium e. Withhold digitalis and notify health care provider if heart rate is irregular

a, b Rationale: Hypokalemia, which can be caused by the use of potassium-depleting diuretics (e.g., thiazides, loop diuretics), is one of the most common causes of digitalis toxicity. Low serum levels of potassium enhance the action of digitalis, causing a therapeutic dose to achieve toxic levels. Hypokalemia can also precipitate dysrhythmias. Monitoring the serum potassium levels of patients receiving digitalis preparations and potassium-depleting diuretics is essential. Patients taking digitalis preparations should be taught how to measure their pulse rate because bradycardia and atrioventricular blocks are late signs of digitalis toxicity. In addition, patients should know what pulse rate would necessitate a call to the health care provider.

A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? a. Administer ordered morphine sulfate .b. Position patient in a semi-Fowler's position. c. Position patient on left side with head of bed flat. d. Instruct patient on the use of relaxation techniques. e. Use a calm, reassuring approach while talking to patient.

a, b, d, e rationale: Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

Mira is managing her hypertension with an ACE inhibitor. Which of the following statements stated by her indicates a need for further teaching? A. I should not take my pills with food B. I need to increase my intake of orange juice, bananas, and green veggies C. I will avoid coffee, tea, and cola D. I will avoid salt substitutes

b

The healthcare provider is performing an assessment on a patient who is taking propranolol (Inderal) for supraventricular tachycardia. Which assessment finding is an indication the patient is experiencing an adverse effect of this drug? A. Dry mouth B. Bradycardia C. Urinary retention D. Paresthesia

b

Lisinopril (Prinivil) is part of the treatment regimen for a client with HF. The nurse monitors the client for which electrolyte imbalance of this drug? A. Hyponatremia B. Hyperkalemia C. Hypokalemia D. Hypernatremia

b Rationale: ACE inhibitors block aldosterone secretion, which results in sodium loss and potassium retention. Hyperkalemia may occur, especially when the drug is taken concurrently with potassium-sparing diuretics.

When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that a. hypertensive crisis may lead to development of acute heart failure in some patients. b. hypertension eventually will lead to heart failure by overworking the heart muscle. c. high BP increases risk for rheumatic heart disease. d. high systemic pressure precipitates papillary muscle rupture.

b Rationale: Hypertension is a primary cause of heart failure because the increase in ventricular afterload leads to ventricular hypertrophy and dilation. Hypertensive crisis may precipitate acute heart failure is some patients, but this patient with stage 1 hypertension may not be concerned about a crisis that happens only to some patients. Hypertension does not directly cause rheumatic heart disease (which is precipitated by infection with group A -hemolytic streptococcus) or papillary muscle rupture (which is caused by myocardial infarction/necrosis of the papillary muscle).

When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as a. administering sedatives to promote rest and decrease myocardial oxygen demand. b. positioning the patient in a high-Fowler's position with the feet horizontal in the bed. c. administering oxygen per mask or nasal cannula. d. encouraging leg exercises to improve venous return.

b Rationale: Positioning the patient in a high-Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload.

Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops a. a drop in heart rate to 54 beats/min. b. a systolic BP <90 mm Hg. c. any symptoms indicating cyanide toxicity. d. an increased amount of ventricular ectopy.

b Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. After 48 hours of continuous use, cyanide toxicity is a possible (though rare) adverse effect. Reflex tachycardia (not bradycardia) is another adverse effect of this medication. Nitroprusside does not cause increased ventricular ectopy.

The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient a. says that the nitroglycerin patch will be used for any chest pain that develops. b. calls when the weight increases from 124 to 130 pounds in a week. c. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime. d. makes an appointment to see the doctor at least once yearly.

b Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as necessary" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. Heart failure is a chronic condition that will require frequent follow-up rather than an annual health care provider examination.

Which of the following types of cardiomyopathy does not affect cardiac output? A. Dilated B. Hypertrophic C. Restrictive D. Obliterative

b rationale: Cardiac output isn't affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. Dilated cardiomyopathy, and restrictive cardomyopathy all decrease cardiac output.

What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention? A. High-fowler's B. Raised 10 degrees C. Raised 30 degrees D. Supine position

c

Which of the following statements would indicate that a patient taking antihypertensive drugs understands the management of hypertension? A. "I need to have my blood pressure checked monthly." B. "I can still smoke while taking these drugs, as long as I cut down." C. "These pills will help control, but not cure, my high blood pressure." D. "When my blood pressure is back to normal, I can stop taking these pills."

c

a pt with congestive heart failure is receiving digoxin. What is the desired effect: A. neck vein distention B. decreased appetite C. increased urinary output D. increased pedal edema

c

when a pt is being taught about the potential adverse effects of an ACE inhibitor, which of the following should be mentioned as possibly occurring when this drug is taken to treat hypertension A. hypokalemia B. nausea C. dry, nonproductive cough D. sedation

c

An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is a. 12-lead electrocardiogram (ECG). b. arterial blood gases (ABGs). c. B-type natriuretic peptide (BNP). d. serum creatine kinase (CK).

c Rationale: BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's a. weight increases from 120 pounds to 122 pounds over 3 days. b. liver is palpable 2 cm below the ribs on the right side. c. serum potassium level is 3.0 mEq/L after 1 week of therapy. d. has 1 to 2+ edema in the feet and ankles in the morning.

c Rationale: Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

The nurse reviews lab studies of a client receiving digoxin (Lanoxin). Intervention by the nurse is required if the results include a A.Serum sodium level of 140 mEq/L. B. Serum digoxin level of 1.2 ng/dL. C.Serum potassium level of 3.0 mEq/L. D. Hemoglobin 14.4 g/dL.

c Rationale: Normal serum potassium level is 3.5-5.0 mEq/L. Hypokalemia may predispose the client to digitalis toxicity. The other lab values are WNL.

A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to a. ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of sodium in the patient's diet. b. instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods. c. assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring. d. educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to reduce the hypervolemia.

c Rationale: The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening; it is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet and teaching about diuretic therapy are appropriate interventions but are not the first nursing actions indicated. There is no evidence that the patient's weight gain is caused by excessive dietary intake of fat or calories, so the answer beginning "instruct the patient in a low-calorie, low-fat diet" describes an inappropriate action

A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is: a. ventricular dilation b. ventricular hypertrophy c. neurohormonal response d. sympathetic nervous system activation

c Rationale: The following mechanisms in heart failure lead to inappropriate fluid retention and additional workload of the heart: activation of the renin-angiotensin-aldosterone system (RAAS) cascade and release of antidiuretic hormone from the posterior pituitary gland in response to low cerebral perfusion pressure that results from low cardiac output.

The nurse monitors the patient receiving treatment for acute decompensated heart failure with the knowledge that marked hypotension is most likely to occur with the IV administration of A. furosemide (Lasix). B. milrinone (Primacor). C. nitroglycerin (Tridil). D. nitroprusside (Nipride).

d

While assessing a pt with angina who is to start Beta Blocker therapy, the nurse is aware that the presence of which condition may be a problem if these drugs are used: A. hypertension B. essential tremors C. exertional angina D. asthma

d

he action of an ACE inhibitor interrupts the renin-angiotensin-aldosterone mechanism, thereby producing which of the following? A. reduced renal blood flow B. reduced sodium and water retention C. increased peripheral vascular resistance D. increased sodium excretion and potassium reabsorption

d

in which of the following disorders would the nurse expect to assess sacral edema in bedridden client? A. DM B. Pulmonary emboli C. Renal failure D. Right-sided heart failure

d

Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations, such as digoxin (Lanoxin). b. calcium-channel blockers, such as diltiazem (Cardizem). c. -adrenergic agonists, such as dobutamine (Dobutrex). d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

d Rationale: ACE-inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium-channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure.

The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is a. weight loss of 2 pounds overnight. b. improvement in hourly urinary output. c. reduction in systolic BP. d. decreased dyspnea with the head of the bed at 30 degrees.

d Rationale: Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in crackles. The other assessment data also may indicate that diuresis or improvement in cardiac output have occurred but are not as useful in evaluating this patient's response.

A hospitalized patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective? a. "I will need to include more high-potassium foods in my diet." b. "I will expect to feel more short of breath for the next few days." c. "I will be sure to take the medication after eating something." d. "I will call for help when I need to get up to the bathroom."

d Rationale: Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparring, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is expected with initiation of -blocker therapy for heart failure, not for ACE-inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

A 55-year-old patient with inoperable coronary artery disease and end-stage heart failure asks the nurse whether heart transplant is a possible therapy. The nurse's response to the patient will be based on the knowledge that a. heart transplants are experimental surgeries that are not covered by most insurance. b. the patient is too old to be placed on the transplant list. c. the diagnoses and symptoms indicate that the patient is not an appropriate candidate. d. candidacy for heart transplant depends on many factors.

d Rationale: Indications for a heart transplant include inoperable coronary artery disease and refractory end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous post-transplant regimen are also considered. Heart transplants are not considered experimental; rather, transplantation has become the treatment of choice for patients who meet the criteria. The patient is not too old for a transplant. The patient's diagnoses and symptoms indicate that the patient may be an appropriate candidate for a heart transplant.

he nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the patient include a. avoid dietary sources of potassium because too much can cause digitalis toxicity. b. take the pulse rate daily and never take digoxin if the pulse is below 60 beats/min. c. take the hydrochlorothiazide before bedtime to maximize activity level during the day. d. notify the health care provider immediately if nausea or difficulty breathing occurs.

d rationale: Difficulty breathing is an indication of acute decompensated heart failure and suggests that the medications are not achieving the desired effect. Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. Digoxin toxicity is potentiated by hypokalemia, rather than hyperkalemia. Patients should be taught to check their pulse daily before taking the digoxin and, if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? a. Taper the patient off his current medications. b. Continue education for the patient and his family. c. Pursue experimental therapies or surgical options. d. Choose interventions to promote comfort and prevent suffering

d rationale: The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not commonly used in the care of hospice patients.

Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? A. Angina pectoris B. Cardiomyopathy C. Left-sided heart failure D. Right-sided heart failure

d rationale: Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure.