BAH Exam 3
A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the clients condition?
Absence of adventitious breath sounds Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.
A nurse is caring for a client who had an onset of chest pain 24 hours ago. The nurse should identify that an increase in which of the following values is diagnostic of a myocardial infarction (MI)?
Creatine-kinase MB Creatine-kinase MB is the isoenzyme specific to the myocardium. Elevate creatine kinase-MB indicates myocardial muscle injury.
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect?
Dyspnea on exertion Dyspnea on exertion is an expected manifestation of dilated cardiomyopathy, due to ventricular compromise and reduced cardiac output.
A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following findings should indicate to the nurse that the medication is effective?
INR 2.0 INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a DVT and is receiving warfarin to reduce the risk of new clot formation and a stroke.
A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?
Lightheadedness Furosemide can cause a substantial drop in blood pressure resulting in lightheadedness or dizziness.
A nurse is caring for a client who was admitted for treatment of left-sided heart failure and is receiving intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first?
Review serum electrolyte values Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance; an adverse effect of loop diuretics. The first action should be to review the client's electrolyte values, particularly the potassium level because the client is at risk for dysrhythmias from hypokalemia.
A nurse is providing teaching to a client who is 2 days post op following a heart transplant. Which of the following statements should the nurse include in the teaching?
You might no longer be able to feel chest pain. Heart transplant clients usually are no longer able to feel chest pain do to the denervation of the heart.