Ch 25: Management of Patients with Complications of Heart Disease

The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information?

"Are you only able to breathe when you are sitting upright?"

The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home?

"I cut back on going up the steps during the day." / "I'm having trouble going up the steps during the day."

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

"I sleep on three pillows each night."

The nurse is teaching a client with heart failure about digoxin. What statements by the client indicate the teaching is effective? Select all that apply.

"I will watch my urine output to be sure that the medication is not affecting my kidneys."; "If I take my digoxin I should have limited episodes of shortness of breath."

The nurse instructs a client with heart failure on restricting sodium in the diet. Which client statement indicates that teaching was effective?

"Lemon juice and herbs can be used to replace salt when cooking."

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

30%

A nurse is caring for a client with a cardiac disorder who is prescribed diuretics. What important factor should the nurse include in this client's teaching plan?

A discussion of the signs and symptoms of electrolyte and water loss.

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound?

A third heart sound (S3).

A client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition?

Acute pulmonary edema.

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided heart failure?

Acute pulmonary edema.

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

Administer epinephrine.

A client with stage IV heart failure has a living will indicating a ventilator may not be used. The client begins experiencing severe dyspnea. What should the nurse who is caring for this client do?

Administer oxygen, morphine, and a bronchodilator for client comfort.

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

Administer the third sublingual nitroglycerin tablet.

The nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will decrease preload?

Administration of a vasodilating drug (as ordered by a health care provider)

The nurse is assessing a client with left-sided heart failure. What assessment finding is expected?

Air hunger

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

An echocardiogram

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?

Arterial blood gases

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure?

Ascites

A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?

Assess for elevated blood urea nitrogen levels.

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing action?

Assess oxygen saturation

The nurse is developing a plan of care for a client following pericardiocentesis. Which interventions should the nurse implement? Choose all that apply.

Assess vital signs every 15 minutes for the first hour; Evaluate the cardiac rhythm; Monitor heart and lung sounds; Record fluid output

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure?

Atrial fibrillation

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

Avoid the intake of processed and commercially prepared foods.

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?

BP and pulse measurements every 15 to 30 minutes

A health care provider in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?

Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours

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

Blood pressure 80/46 mm Hg

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure?

Brain natriuretic peptide (BNP)

Which is a key diagnostic indicator of heart failure?

Brain natriuretic peptide (BNP)

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?

Call for a chest x-ray.

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

Call for help and begin chest compressions.

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

Canned peas

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

Check the client's potassium level.

A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?

Class I (Mild)

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

Class III (Moderate)

The nurse is caring for a client in the hospital with chronic heart failure who has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, the client becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?

Class III (Moderate)

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

Decrease in central venous pressure (CVP)

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

Decreased left ventricular pumping

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

Decreased left ventricular workload

A client is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client?

Digoxin immune FAB

Which medication reverses digitalis toxicity?

Digoxin immune FAB

The nurse is caring for a client experiencing a rapidly developing pericardial effusion. Which assessment findings indicate to the nurse that the client is developing cardiac tamponade? Select all that apply.

Distant heart sounds; Dyspnea; Jugular vein distention; Tachycardia

Which assessment parameter is important for the client diagnosed with congestive heart failure?

Distended veins

The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?

Dizziness

The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs?

Dopamine

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

Dyspnea on exertion

The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?

Dyspnea on exertion

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

Echocardiogram

The diagnosis of heart failure is usually confirmed by which of the following?

Echocardiogram

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

Echocardiogram

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

Echocardiogram

The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?

Elevate the head of the bed.

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

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

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

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

The nurse is interviewing a client during an initial visit at a cardiologist's office. What symptom will the nurse expect to find as an early symptom of chronic heart failure?

Fatigue

The nurse visits the home of a client with heart failure. Which assessment finding indicates to the nurse that the client's tolerance to activity is deteriorating?

Fatigue after walking to answer the door

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

Furosemide

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

Gradual unexplained weight gain

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

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

A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?

Heart failure

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

Heart failure (HF)

A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber?

Heart rate of 55 beats per minute

The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed?

Heart transplant

The nurse is preparing to administer hydralazine and isosorbide dinitrate. When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse?

Hold the medication and call the health care provider.

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

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

The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Due to the client's high risk for developing ________ as a result of the prescribed medication, the nurse focuses on monitoring the client for ____________

Hypokalemia; Ventricular arrhythmia

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

Inadequate cardiac output

Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?

Increased pulmonary artery diastolic pressure

The pathophysiology of pericardial effusion is associated with all of the following except:

Increased venous return.

The nurse is receiving a client from the emergency in cardiogenic shock. What mechanical device does the nurse anticipate will be inserted into the client?

Intra-aortic balloon pump

A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client?

Intubation and mechanical ventilation

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

JVD is noted 4 cm above the sternal angle.

The nurse identifies which symptom as a characteristic of right-sided heart failure?

Jugular vein distention (JVD)

The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?

Left ventricular function

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

Lisinopril

A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?

Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation.

Which feature is the hallmark of systolic heart failure?

Low ejection fraction (EF)

Which is the hallmark of heart failure?

Low ejection fraction (EF)

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

Mask

A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment?

Moist, gurgling respirations

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

Monitor blood pressure frequently

A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)?

Myocardial ischemia

The nurse is caring for a client with severe compensated heart failure. What human brain natriuretic peptide (BNP) medication may be used in a critical care unit with hemodynamic monitoring?

Natrecor

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

Nausea and vomiting

The nurse is working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for the nurse to closely monitor an older adult receiving digitalis preparations for cardiac disorders?

Older adults are at increased risk for toxicity.

A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis?

Orthopnea

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

Orthopnea

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

Orthopnea

Which describes difficulty breathing when a client is lying flat?

Orthopnea

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

Peripheral edema

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

Persistent cough

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

Pitting edema

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?

Potassium

The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide?

Potassium level of 3.1

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient?

Potassium levels

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

Preload

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?

Pulmonary congestion

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

Pulmonary crackles

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

Pulmonary embolism

What disease process(es) contributes to chronic heart failure? Select all that apply.

Renal failure; Tachyarrhythmias; Valvular disease

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

Respiratory alkalosis

The nurse recognizes which symptom as a classic sign of cardiogenic shock?

Restlessness and confusion

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

Spironolactone

Which is a manifestation of right-sided heart failure?

Systemic venous congestion

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

The client is going into cardiogenic shock.

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

The client says his rings have become tight and are difficult to remove.

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

The development of left-sided heart failure

The client asks the nurse why a stress test is needed. What statement best explains the rationale for the health care provider to order a cardiac stress test?

The health care provider wants to identify if the heart failure is from coronary artery disease.

A nurse is teaching a client about heart failure. What will the nurse explain is causing the heart to fail?

The heart cannot pump sufficient blood to meet the body's metabolic needs.

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

The level of physical activity each allows

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

Titrate oxygen therapy.

The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts?

Treat pulseless ventricular tachycardia.

The student nurse is caring for a client with heart failure. Diuretics have been prescribed. What method might be used with a debilitated client to help the nurse evaluate the client's response to diuretics?

Using a urinary catheter

A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?

Ventricular assist device (VAD)

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

Vision changes.

A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?

Visual disturbances.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Weighing the client daily at the same time each day

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

Weight