Cardiac problems

39. The nurse has difficulty hearing heart sounds in a client with pericarditis. Which is the priority action of the nurse? a. Assessing heart sounds with a Doppler b. Increasing the intravenous flow rate c. Administering oxygen by non-rebreather mask d. Assessing the client for Beck's triad

: D Heart sounds that become muffled or more difficult to auscultate in a client with pericarditis may indicate the presence of tamponade, a medical emergency. The health care provider should be notified after assessment data is obtained. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 16 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential) MSC: Integrated Process: Nursing Process (Implementation)

A client with heart failure develops an increase in preload. Which mechanism contributes to this increase? a. A reduction in sympathetic stimulation b. Stimulation of coronary baroreceptors c. Activation of the renin-angiotensin-aldosterone system d. Arterial vasodilation and subsequent increase in oxygen consumption

ANS: C Activation of the renin-angiotensin-aldosterone system increases preload by contributing to vasoconstriction and fluid retention, which in turn reduce the force of contraction and cardiac output.

4. A client with systolic dysfunction has an ejection fraction of 38%. The nurse expects to observe which physiologic change? a. An increase in stroke volume b. A decrease in tissue perfusion c. An increase in oxygen saturation d. A decrease in arterial vasoconstriction

- ANS: B In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerances. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 5 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

1. A client with heart failure develops an increase in preload. Which mechanism contributes to this increase? a. A reduction in sympathetic stimulation b. Stimulation of coronary baroreceptors c. Activation of the renin-angiotensin-aldosterone system d. Arterial vasodilation and subsequent increase in oxygen consumption

- ANS: C Activation of the renin-angiotensin-aldosterone system increases preload by contributing to vasoconstriction and fluid retention, which in turn reduce the force of contraction and cardiac output. DIF: Cognitive Level: Comprehension REF: p. 765 OBJ: Learning Outcome 9 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

2. A client is admitted with early-stage heart failure. Which immediate compensatory response would the nurse expect to see in this client? a. Decreased stroke volume, causing decreased urinary output b. Arterial vasodilation, resulting in pooling of blood in the extremities c. Stimulation of adrenergic receptors, causing an increase in heart rate d. Myocardial hypertrophy, resulting in an initial increase in oxygen saturation

- ANS: C In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. DIF: Cognitive Level: Comprehension REF: p. 765 OBJ: Learning Outcome 9 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

3. A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A drop in blood pressure and urine output b. An increase in creatinine and lower extremity edema c. An increase in heart rate and respiratory rate d. An increase in oxygen saturation

- ANS: C In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. The blood pressure will remain the same or elevate slightly. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 9 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

48. A client with heart failure has a blood pressure of 140/60 mm Hg. How will the nurse interpret this finding? a. Normal proportional pulse pressure b. Severely compromised cardiac output c. Hypertensive blood pressure d. Narrowed pulse pressure

: A A proportional pulse pressure less than 25% is indicative of a severely compromised cardiac output. The proportional pulse pressure of this client is 57%. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 5 TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Evaluation)

5. Which client is most at risk of developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes two packs of cigarettes daily d. Older man who has had a right ventricular myocardial infarction

: A Although most individuals with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, CAD (coronary artery disease), and hypertension. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 10 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

16. The client with heart failure is prescribed enalapril (Vasotec). What is the nurse's focus for teaching? a. Avoiding salt substitutes b. Taking medication with food c. Avoiding aspirin or aspirin-containing products d. Holding this medication if the pulse rate is below 74 beats/min

: A Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcomes 12, 13 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies) MSC: Integrated Process: Nursing Process (Planning)

27. A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention? a. Assessing respiratory status b. Monitoring the serum electrolyte levels c. Administering intravenous fluids d. Inserting a Foley catheter

: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 3 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care) MSC: Integrated Process: Nursing Process (Implementation)

34. A client has just undergone a balloon valvuloplasty. For which complication of this procedure should the nurse monitor this client? a. Bleeding b. Acute tubular necrosis c. Short-term memory loss d. Pulmonary hypertension

: A Clients undergoing valvuloplasty are at higher risk of bleeding from the catheter insertion site. This is because of the use of a large-bore catheter for the arterial puncture needed to perform the procedure. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 19 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential) MSC: Integrated Process: Nursing Process (Assessment)

12. A client asks the nurse why it is important to be weighed every day if he or she has right-sided heart failure. How will the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Weighing you every day will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcomes 1, 2 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care) MSC: Integrated Process: Teaching/Learning

50. An older adult client is admitted with fluid volume excess. Which diagnostic or laboratory study would best assist in the diagnosis of heart failure? a. Echocardiography b. Chest x-ray c. T4, TSH d. Arterial blood gases

: A Echocardiography is considered the best tool for the diagnosis of heart failure. DIF: Cognitive Level: Comprehension REF: p. 780 OBJ: Learning Outcome 14 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential) MSC: Integrated Process: Nursing Process (Assessment)

25. Which assessment finding alerts the nurse to the possibility of pulmonary edema in an older adult? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate

: A Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 16 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

54. A client in severe heart failure is to receive nesiritide (Natrecor). Which intervention is essential prior to starting this medication? a. Insert a separate IV access. b. Prepare a test bolus dose. c. Prepare the piggyback line. d. Administer IV Lasix first.

: A Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 13 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies) MSC: Integrated Process: Nursing Process (Implementation)

38. The home care nurse is assessing the client receiving antibiotic therapy in the home for infective endocarditis. Which of the following clinical manifestations requires re-evaluation of the treatment regimen? a. Temperature: 101.6° F b. Clubbing of fingers c. Petechiae d. Pulse pressure of 36 mm Hg

: A Persistent or new fever in a client receiving antibiotic therapy for infective endocarditis may indicate inappropriate or ineffective therapy. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 21 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential) MSC: Integrated Process: Nursing Process (Evaluation)

15. The client with heart failure is experiencing respiratory difficult. Which is the nurse's priority action? a. Place the client in a high Fowler's position. b. Suction the client. c. Auscultate the client's heart and lungs. d. Place the client on fluid restriction.

: A Placing a client in a high Fowler's position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 7 TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness) MSC: Integrated Process: Nursing Process (Implementation)

51. How will the nurse position the client in severe heart failure? a. High Fowler's, pillows under arms b. Semi-Fowler's, with legs elevated c. High Fowler's, with legs elevated d. Semi-Fowler's, on their left side

: A Placing the client in a high Fowler's position, with pillows under their arms, allows for maximum chest expansion. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 15 TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort) MSC: Integrated Process: Nursing Process (Implementation)

7. A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction will the nurse give to the client? a. "Come to the clinic for evaluation." b. "Increase fluid intake during waking hours." c. "Use an over-the-counter cough suppressant before going to sleep." d. "Use two pillows to facilitate drainage of postnasal secretions."

: A The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcomes 3, 4 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care) MSC: Integrated Process: Nursing Process (Assessment)

37. Which precautions are appropriate when providing care to a client with infective endocarditis? a. Standard precautions b. Enteric precautions c. Protective isolation d. Respiratory isolation

: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 3 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control) MSC: Integrated Process: Nursing Process (Implementation)

53. A client with heart failure is due to receive enalapril (Vasotec). The blood pressure is 98/50 mm Hg. Which is the nurse's best action? a. Administer the Vasotec. b. Wait 1 hour and then administer the Vasotec. c. Hold the Vasotec. d. Notify the physician.

: A The nurse should administer the medication. Generally, the health care provider will maintain the client's blood pressure between 90 and 110 mm Hg. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 13 TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort) MSC: Integrated Process: Nursing Process (Planning)

11. The nurse assesses a client and notes the presence of an S3 gallop. Which is the nurse's priority intervention? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcomes 10, 11 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential) MSC: Integrated Process: Nursing Process (Assessment)

1. Which conditions are caused by left-sided heart failure? (Select all that apply.) a. Hypertensive disease b. Crackles heard c. Enlarged liver and spleen d. Confusion e. Pulmonary hypertension f. Dependent edema g. S3/S4 gallop h. Cough worsens at night

: A, B, D, G, H Left-sided failure occurs with decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature on. Signs will be noted before the right atrium or ventricle. DIF: Cognitive Level: Knowledge REF: p. 768, Charts 37-1 and 37-2 OBJ: Learning Outcome 10 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

2. Which laboratory results does the nurse expect in the client with heart failure? (Select all that apply.) a. Hemoglobin, 14.2 g/dL; hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria

: A, B, E, F The hematocrit is low (should be 42.6%), indicating a dilutional ratio of RBCs to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 14 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential) MSC: Integrated Process: Nursing Process (Evaluation)

17. Which is the priority intervention for a client who has received the first dose of captopril (Capoten)? a. Administer this medication 1 hour before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level for hypokalemia.

: B Administration of the first dose of ACE inhibitors is associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcomes 12, 13 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies) MSC: Integrated Process: Nursing Process (Implementation)

35. A client is preparing to be discharged home following mitral valve replacement. Which statement indicates that the client requires further education? a. "I won't be able to carry heavy loads for at least 6 months." b. "I will have my teeth cleaned by the dentist in 2 weeks." c. "I will avoid eating foods high in vitamin K." d. "I can use my electric razor to shave."

: B Clients who have defective or repaired valves are at high risk of endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk of endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 20 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential) MSC: Integrated Process: Nursing Process (Evaluation)

55. In Healthy People 2010, which is a priority of the primary nurse caring for older adults with heart failure? a. Reduce hospitalizations by treating more clients at home. b. Provide follow-up care by the multidisciplinary team. c. Perform follow-up phone calls, delegated to the unit secretary. d. Evaluate client compliance with medications by the home health aide.

: B Follow-up by the multidisciplinary team decreases the incidence of frequent hospitalizations by maintaining tighter evaluation and control. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 7 TOP: Client Needs Category: Health Promotion and Maintenance (Disease Prevention) MSC: Integrated Process: Nursing Process (Planning) MULTIPLE RESPONSE

52. A nurse is instructing a client with heart failure on energy conservation. Which is the best instruction? a. "Walk until you become short of breath and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day."

: B Gathering all supplies needed for a chore at one time decreases the amount energy needed. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 7 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

32. Which assessment finding does the nurse expect in the client with mitral insufficiency? a. A systolic click on auscultation b. A high-pitched holosystolic murmur c. Angina with exertion d. A cough with hemoptysis

: B Incomplete closure of the mitral valve allows backflow of blood into the left atrium when the ventricle contracts, resulting in a holosystolic, high-pitched murmur DIF: Cognitive Level: Knowledge REF: p. 779, Chart 37-7 OBJ: Learning Outcome 18 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

20. The client with heart failure has been ordered to receive a daily nitroglycerin transdermal patch. Which is the priority nursing intervention? a. Placing an occlusive dressing over the patch b. Removing the patch overnight c. Rotating the skin site of nitroglycerin administration d. Administering a larger loading dose before the initiation of therapy

: B Providing a 12-hour nitrate-free period out of every 24 hours helps prevent the development of tolerance to the vasodilating effects of nitrates. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 13 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies) MSC: Integrated Process: Nursing Process (Implementation)

41. A nurse is caring for a client admitted with tachycardia, a pericardial friction rub, and the development of a murmur. Which finding in the client's history leads the nurse to suspect rheumatic carditis? a. The client was vacationing in the tropics 2 weeks ago. b. The client has had a sore throat for 1 week. c. The client is currently taking antibiotics. d. The client has a history of alcoholism.

: B Rheumatic carditis is a sensitivity response occurring after infection with group A beta-hemolytic streptococci. The client's history of a sore throat is suspicious for rheumatic carditis because of the clinical manifestations at admission. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 3 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care) MSC: Integrated Process: Nursing Process (Assessment)

8. Which statement made by a client would alert the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight." c. "I wake up coughing every night." d. "I have trouble catching my breath."

: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing could all be results of left-sided heart failure. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 10 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

33. The client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. How will the nurse respond? a. "You are at greater risk for a heart attack, and the anticoagulants can reduce that risk." b. "Blood clots form more easily on artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg, making blood return to the heart much slower." d. "The surgery left a lot of small clots in your heart and lungs. The anticoagulants will slowly dissolve these."

: B Synthetic valve prostheses and scar tissue provide a surface on which platelets can aggregate easily and initiate the formation of blood clots. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 20 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential) MSC: Integrated Process: Teaching/Learning

10. The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans.

: B The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 11 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

40. Which assessment finding does the nurse expect in a client with pericarditis? a. An irregular heart rate that speeds up and slows down b. A friction rub at the left lower sternal border c. The presence of a gallop rhythm d. A substernal lift at the apex

: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. DIF: Cognitive Level: Comprehension REF: p. 785 OBJ: Learning Outcome 21 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

30. What clinical manifestation alerts the nurse to the possibility that the client's mitral stenosis has progressed? a. The client's oxygen saturation is 92%. b. The client has dyspnea on exertion. c. The client has a systolic crescendo-decrescendo murmur. d. The client experiences a loss of strength in the upper extremities.

: B The development of dyspnea on exertion occurs as the mitral valvular orifice narrows and pressure in the lungs increases. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 18 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential) MSC: Integrated Process: Nursing Process (Assessment)

29. Which assessment finding does the nurse expect in the client with mitral valve prolapse? a. Rumbling apical diastolic murmur b. Midsystolic click and late systolic murmur c. An S3 coupled with a high-pitched systolic murmur d. Continuing, loud diastolic murmur radiating to the left axilla

: B The mitral valve separates the left atrium from the left ventricle. The prolapse permits backflow of blood during mid- to late systole, resulting in a midsystolic click and a late systolic murmur at the heart apex. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 18 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

44. Which teaching is essential for a client discharged after a heart transplant who is prescribed cyclosporine (Sandimmune)? a. "Use a soft-bristled toothbrush." b. "Avoid crowds and people who are sick." c. "Change positions slowly to avoid hypotension caused by the medication." d. "Do not take this medication if your pulse rate is lower than 60 beats/min."

: B These agents cause immunosuppression, leaving the client more vulnerable to infection. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 22 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies) MSC: Integrated Process: Nursing Process (Implementation)

23. A client with heart failure is going through rehabilitation to increase his or her activity tolerance. The nurse will stop the client's activity if which symptom is assessed? a. Oxygen saturation of 95% b. Respiratory rate of 20 breaths/min c. Systolic blood pressure change from 136 to 96 mm Hg d. Heart rate increase from 86 to 100 beats/min

: C A blood pressure change (increase or decrease) of more than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or following activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 7 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Evaluation)

43. The nurse cautions the client who has received a heart transplant to change positions slowly. Why is this instruction a priority? a. Rapid position changes can create shear forces and disrupt vascular sutures. b. The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure. c. The new heart is denervated and unable to respond to decreases in blood pressure caused by position changes. d. The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.

: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 22 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Implementation)

6. Which client statement alerts the nurse to possible heart failure? a. "I am drinking more water than usual." b. "I have been awakened by the need to urinate at night." c. "I have to stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 5 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

49. An older adult client with heart failure states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." Which is the nurse's best response? a. "Would you like to talk about it more?" b. "You're lucky to have such a devoted daughter." c. "You feel as though you are a burden." d. "You seem depressed. I'll get the doctor to order an antidepressant."

: C Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allows the client to respond safely and honestly. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 6 TOP: Client Needs Category: Health Promotion and Maintenance (Family Systems) MSC: Integrated Process: Caring

31. Which assessment finding does the nurse expect in a client diagnosed with aortic stenosis? a. Bounding arterial pulse b. Slow, faint arterial pulse c. Narrowed pulse pressure d. Elevated systolic and diastolic pressures

: C In aortic stenosis, the client presents with a narrowed pulse pressure when the blood pressure is assessed. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 18 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

24. An older adult client with heart failure has developed atrial fibrillation. What diagnostic or laboratory test would the nurse expect to be ordered? a. Serum anion gap b. Serum sodium level c. T4 (thyroxine) and TSH (thyroid-stimulating hormone) d. Serum creatinine

: C In older adults with atrial fibrillation, T4 and TSH levels should be checked because hypo- or hyperthyroidism can cause or aggravate heart failure. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 14 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

42. Which instructions are essential in a teaching plan for a client with hypertrophic cardiomyopathy (HCM)? a. "Take your digoxin at the same time every day." b. "You should begin an aerobic exercise program." c. "You should report episodes of dizziness or fainting." d. "You may have a maximum of two alcoholic drinks weekly."

: C The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur, because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 23 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Implementation)

14. Which nursing diagnosis would be considered a priority for the client with heart failure? a. Anxiety related to hospitalization b. Altered Health Maintenance c. Impaired Gas Exchange d. Altered Comfort

: C The client with heart failure experiences impaired gas exchange related to inadequate cardiac pump function. Although all other diagnoses presented here may be manifested, Impaired Gas Exchange is the priority because it is the most life-threatening. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 15 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

18. The client with moderate heart failure is being discharged. Which is of priority to teach the client? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Stop your activity and rest at the first sign of chest pain." c. "Weigh yourself every day in the morning before breakfast." d. "Do not take a double dose if you forget to take your digoxin."

: C Weight gain is the most reliable indicator of fluid retention associated with heart failure. The client should weigh himself or herself early in the morning, before breakfast. The client should be instructed to limit fluid; 3 quarts is too much fluid for the client. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 7 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Implementation)

45. A client is classified (staged) at level A heart failure. What will the nurse teach the client? a. "Take digoxin daily." b. "Limit activity when short of breath." c. "Control blood pressure at 140/80 or below." d. "Maintain a no added salt diet."

: D A stage A client is identified as a high risk for heart failure. Education should be focused on the prevention of hypertension, coronary artery disease, and valvular disease, which are the leading causes of heart failure. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 2 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care) MSC: Integrated Process: Teaching/Learning

47. Which question will best help the nurse to assess the activity level of a client with a history of heart failure? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk up stairs without fatigue?" c. "Do you wake up suddenly during the night with breathlessness?" d. "Do you become fatigued or develop heaviness in your arms or legs that you didn't have before?"

: D Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine if the client's activity is the same or worse, or whether the client identifies that there is a decrease in activity level. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 5 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Evaluation)

26. A client with a history of heart failure is being discharged. Which instruction will assist the client in the prevention of complications associated with heart failure? a. "Drink at least 2 L of fluids daily." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily wearing the same amount of clothing."

: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure are increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 7 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

21. Which intervention is essential to teach the client starting on digoxin therapy? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase fluid intake to at least 3000 mL/day." c. "Do not take this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 13 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies) MSC: Integrated Process: Nursing Process (Implementation)

9. Which client is at highest risk for the development of high-output heart failure? a. Young woman taking oral contraceptives b. Middle-aged man who broke an ankle while training for a marathon c. Older adult with dehydration 5 years after having a myocardial infarction d. Young woman taking large doses of Synthroid to promote weight loss

: D Hyperthyroidism, whether caused by increased synthesis of thyroid hormones or overdose of exogenous thyroid hormone, increases heart rate and contractility. This can increase the workload of the heart without allowing sufficient time for perfusion and oxygenation. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 5 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

22. A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). Which assessment finding alerts the nurse to a serious side effect? a. Cough b. Headache c. Bradycardia d. Hypokalemia

: D Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headaches may occur with any medication, and is not a serious side effect. Bradycardia is not likely to occur with this medication. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 13 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies) MSC: Integrated Process: Nursing Process (Analysis)

28. Which assessment finding supports a diagnosis of impaired tissue perfusion in the client with heart failure? a. Carotid bruit b. A dry hacking cough c. A positive Allen's test d. Dyspnea on exertion

: D Indications of poor tissue perfusion are activity intolerance, which includes dyspnea on exertion. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 17 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Assessment)

46. A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance but I don't want to become a vegetable." What is the nurse's best response? a. "Would you like to speak with a priest?" b. "I'll get a psychiatrist to talk with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advanced directives?"

: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of the sympathetic stimulation. The best action is to allow her or him to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 8 TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms) MSC: Integrated Process: Nursing Process (Implementation)

13. A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. Which primary collaborative intervention should the nurse perform? a. Maintain the head of the bed in a high Fowler's position. b. Keep the client on bedrest, with passive range of motion. c. Limit visitors and activity to a minimum. d. Administer loop diuretics.

: D The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering the diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 15 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Implementation)

36. A young adult presents with a fever, symptoms of heart failure, and a murmur. Which additional data will the nurse obtain? a. Family history of coronary artery disease b. Recent travel to third-world countries c. Whether the client is responsible for cleaning pet litter boxes d. History of any systemic infection or dental work within the past month

: D The clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 3 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control) MSC: Integrated Process: Nursing Process (Assessment)

19. The client who just started taking isosorbide dinitrate (Isordil) complains of a headache. What is the nurse's first action? a. Titrate oxygen to relieve headache. b. Hold the next dose of Isordil. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

: D The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. DIF: Cognitive Level: Application REF: N/A for Application and above OBJ: Learning Outcome 13 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies) MSC: Integrated Process: Nursing Process (Implementation)