CARDIAC PT 3

The nurse is planning discharge teaching for a client who just received a permanent pacemaker. Which topics should the nurse include? Select all that apply. 1. Avoid MRI scans 2. Do not place cell phones directly over the pacemaker 3. Notify airport security when traveling 4. Perform shoulder range-of-motion exercises 5. Refrain from using microwave ovens

ANS : 1,2,3 Avoid MRI scans, which can affect or damage a pacemaker (Option 1). Avoid carrying a cell phone in a pocket directly over the pacemaker and, when talking on a cell phone, hold it to the ear on the opposite side of the pacemaker (Option 2). Notify airport security of a pacemaker; a handheld screening wand should not be held directly over the device (Option 3). (Option 4) The client should avoid lifting the arm above the shoulder on the side of the pacemaker until approved by the HCP as this can cause dislodgement of the pacemaker lead wires. (Option 5) Microwave ovens are safe to use and do not interfere with pacemakers.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs) 2. B-type natriuretic peptide (BNP) 3. Cardiac enzymes (CK-MB) 4. Chest x-ray

ANS : 2 Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. (Option 1) ABGs will be helpful in determining the client's oxygenation status and acid-base balance but will not determine whether the cause of the dyspnea is cardiac or respiratory. (Option 3) CK-MB is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure. (Option 4) A chest x-ray can show heart enlargement in the case of heart failure and may show infiltrations in the lungs. Pneumonia can also exacerbate COPD and can be confused with heart failure infiltrates. Chest x-ray is not as specific to heart failure as the BNP lab test.

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply. 1. Crackles in lung bases 2. Increased abdominal girth 3. Jugular venous distension 4. Lower extremity edema 5. Orthopnea

ANS : 2,3,4 Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities (Option 4). Jugular venous distension (Option 3). Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation (Option 2). Hepatomegaly due to hepatic venous congestion. (Options 1 and 5) Orthopnea (dyspnea with recumbency), paroxysmal nocturnal dyspnea (PND), and crackles in lung bases are clinical manifestations of left-sided heart failure. Blood is not effectively pumped into systemic circulation, resulting in the backup of blood into the pulmonary vessels that causes congestion of the pulmonary vessels and, potentially, pulmonary edema. Pulmonary hypertension and right-sided heart failure typically present with dyspnea on exertion rather than orthopnea or PND.

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first? 1. Assess incision for bleeding or hematoma formation 2. Auscultate bilateral anterior and posterior lung sounds 3. Initiate continuous cardiac monitoring 4. Reestablish IV fluids and postoperative antibiotics

ANS : 3 If the pacemaker is not working properly (eg, failure to capture, failure to sense), the health care provider should be contacted immediately (Option 3). (Option 1) Checking for bleeding or hematoma formation at the insertion site is appropriate but should occur after attaching the cardiac monitor. (Option 2) Postoperative lung sounds are auscultated to assess for atelectasis, but lung assessments do not take priority over ensuring pacemaker functionality. (Option 4) IV fluids and postoperative antibiotics help to reestablish fluid volume and prevent infection, respectively, and should be initiated after cardiac monitoring.

The nurse should assess the client with left-sided heart failure for which findings? Select all that apply. 1. dyspnea 2. jugular vein distention (JVD) 3. crackles 4. right upper quadrant pain 5. oliguria 6. decreased oxygen saturation levels

. 1,3,5,6. Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure

Which position is best for a client with heart failure who has orthopnea? 1. semisitting (low Fowler's position) with legs elevated on pillows 2. lying on the right side (Sims' position) with a pillow between the legs 3. sitting upright (high Fowler's position) with legs resting on the mattress 4. lying on the back with the head lowered (Trendelenburg's position) and legs elevated

3. Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg's position.

What is the major goal of nursing care for a client with heart failure and pulmonary edema? 1. Increase cardiac output. 2. Improve respiratory status. 3. Decrease peripheral edema. 4. Enhance comfort.

1. Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.

The nurse identifies that a patient has sinus bradycardia with a heart rate at 45 bpm. What should the nurse do first? 1. Assess mental status and blood pressure 2. Prepare to administer intravenous atropine 3. Assess peripheral pulses on all four extremities 4. Determine if an apical-radial pulse deficit is present

1. Sinus bradycardia may be well tolerated in some patients and assessment is needed before treating. If decreased mental status and hypotension are presentIV atropine may be indicated.

. The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? 1. Assess respiratory status. 2. Draw blood for laboratory studies. 3. Insert a Foley catheter. 4. Weigh the client.

1. The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and CRT less than three (3) seconds.

1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger.

1. The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form.

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify the health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct the client to remove the saltshaker from the dinner table. 4. Encourage the client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2. The client should not take digoxin if the radial pulse is less than 60. 3. The client should be on a low-sodium diet to prevent water retention.

The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of: 1. maintaining a high-fiber diet. 2. walking 2 miles (3.2 km) every day. 3. obtaining daily weights at the same time each day. 4. remaining sedentary for most of the day.

3. Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the healthcare provider (HCP) if there has been a weight gain of 2 lb (0.91 kg) or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure.

Which are indications that a client with a history of left-sided heart failure is developing pulmonary edema? Select all that apply. 1. distended jugular veins 2. dependent edema 3. anorexia 4. coarse crackles 5. tachycardia

4,5. Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position.

4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead.

The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. The nurse is confident that the client has understood the teaching when the client identifies which potential complications? Select all that apply. 1. becoming increasingly short of breath at rest 2. weight gain of 2 lb (0.9 kg) or more in 1 day 3. high intake of sodium for breakfast 4. having to sleep sitting up in a reclining chair 5. weight loss of 2 lb (0.9 kg) in 1 day

. 1,2,4. If the client will call the healthcare provider (HCP) when there is increasing shortness of breath, weight gain over 2 lb (0.9 kg) in 1 day, and need to sleep sitting up, this indicates an understanding of the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodiumrestricted diet, the client would not need to notify the HCP if he or she had consumed a high-sodium breakfast. Instead, the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future.

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily

2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium

A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action? 1. Auscultate the client's breath sounds 2. Encourage the client to increase fluid intake 3. Report the findings to the health care provider (HCP) 4. Start an intravenous line for diuretic administration

ANS 1 The nurse should assess the lung sounds for crackles and report to the HCP, who can prescribe loop diuretics. (Option 2) The client with heart failure is at risk for fluid overload. Fluids should not be encouraged before consulting with the HCP to determine the cause of decreased urine output. If this client had dehydration, fluids would be encouraged. (Options 3 and 4) Always assess the client first, and then report to the HCP. A diuretic may be prescribed by the HCP if crackles and dyspnea are present.

A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply. 1. "I don't plan on eating any more frozen meals." 2. "I plan to take my diuretic pill in the morning." 3. "I will weigh myself at least every other day." 4. "I'm going to look into joining a cardiac rehabilitation program." 5. "Ibuprofen works best for me when I have pain."

ANS 3,5 he use of any nonsteroidal anti-inflammatory drugs (NSAIDS) is contraindicated as they contribute to sodium retention, and therefore fluid retention (Option 5). To monitor fluid status, clients are instructed to weigh themselves daily, at the same time, with the same amount of clothing, and on the same scale (Option 3).

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention? 1. The client cannot remember what was done yesterday 2. The client has a painful red area on the buttocks 3. The client has new dependent edema of the feet 4. The client has strong, foul smelling urine

ANS : 3 New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) and treatment.