Med Surg 28
A client with heart failure informs the nurse he has not had a bowel movement in 2 days. Why would it be important for the nurse to obtain an order for a stool softener? A) Straining causes the Valsalva maneuver, which can cause dangerous effects. B) The client should not develop hemorrhoids. C) The client can develop a rectal fissure, which will increase pain levels. D) The client should have a bowel movement every day to avoid development of an intestinal obstruction.
A Feedback: Avoid activities that engage the Valsalva maneuver, such as straining with bowel elimination or using the arms to pull and reposition oneself. The Valsalva maneuver increases intrathoracic pressure, reduces right atrial filling, triggers tachycardia, and increases blood pressure. The client's discomfort would be increased if hemorrhoids or a rectal fissure developed but would not engage the Valsalva maneuver. It is not necessary for the client to have a bowel movement on a daily basis. 31
The nurse is administering captopril (Capoten) to a client with a diagnosis of heart failure. What type of medication does the nurse inform the client is taking? A) An angiotensin converting enzyme inhibitor (ACE) inhibitor B) A thiazide diuretic C) An angiotensin receptor blocker (ARB) D) A calcium channel blocker
A Feedback: Captopril is an ACE inhibitor. Although the other medications may be used alone or in conjunction with other medications, the ACE inhibitor is a standard medication used in heart failure unless not tolerated by the client. 29
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? A) Class I (Mild) B) Class II (Mild) C) Class III (Moderate) D) Class IV (Severe)
A Feedback: Class I is when ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken. 13
The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean? A) There is excess fluid volume in the interstitial space in areas affected by gravity. B) There is excess fluid volume in the venous system of the lower extremities. C) There is excess fluid volume in the arterial system of the lower extremities. D) There is excess fluid volume in the hepatic system.
A Feedback: Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area. Options B, C, and D are not descriptive of pitting edema. 9
A client is scheduled for a multiple gated acquisition (MUGA) scan the following day. What medication should the nurse be sure not to administer the morning of the procedure? A) Furosemide (Lasix) B) Acetaminophen (Tylenol) C) Morphine sulfate D) Guaifenesin (Mucinex)
A Feedback: Diuretics are contraindicated the morning of a test to avoid any interruptions for urination. Clients are also medicated to relieve a cough that may cause movement during the test so administration of Mucinex is not contraindicated. Tylenol and morphine are not contraindicated the morning of the test. 24
You are working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for you to closely monitor an older adult receiving digitalis preparations for cardiac disorders? A) Older adults are at increased risk for toxicity. B) Older adults are at increased risk for cardiac arrests. C) Older adults are at increased risk for hyperthyroidism. D) Older adults are at increased risk for asthma.
A Feedback: Older adults receiving digitalis preparations are at increased risk for toxicity because of the decreased ability of the kidneys to excrete the drug due to age-related changes. The margin between a therapeutic and toxic effect of digitalis preparations is narrow. Using digitalis preparations does not increase the risk of cardiac arrests, hyperthyroidism, or asthma. 6
The nurse is caring for a client with right-sided heart failure who has ascites and hepatomegaly. What interventions can the nurse first provide to ensure the client has adequate nutritional intake? A) Offer small, frequent feedings. B) Give a medication to stimulate the appetite C) Give the client anything he wants to eat. D) Offer three larger meals throughout the day.
A Feedback: Preventing stomach distention increases the space in the thoracic cavity for lung expansion. Medication for appetite stimulation would not be given prior to trying the small, frequent feedings. The client should not be given foods high in sodium and should not be given any foods they desire. Three large meals would distend the abdomen and the client would not increase intrathoracic pressure. 17
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? A) Intubation and mechanical ventilation B) Face mask with nonrebreather C) Oxygen cannula at 6 L/minute D) Venturi mask at 35%
A Feedback: The client's respiratory status is severely compromised and has developed signs of respiratory failure. When respiratory failure occurs, the client is intubated and oxygen is administered under continuous positive airway pressure or with mechanical ventilation with positive end-expiratory pressure. A face mask, cannula, or Venturi mask will not deliver the concentration or ventilatory support that an endotracheal tube with mechanical ventilation will provide. 33
The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump? A) Echocardiogram B) A pulmonary arteriography C) A chest radiograph D) Electrocardiogram
A Feedback: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm cor pulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart's conduction system. 12
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? A) "Are you only able to breathe when you are sitting upright?" B) "How far can you walk without becoming short of breath?" C) "Are you coughing up blood at night?" D) "Are you urinating excessively at night?"
A Feedback: To determine if a client is having orthopnea, the nurse needs to ask about the inability to breathe unless sitting upright. Determining how far the client can walk without becoming short of breath would indicate exertional dyspnea. Coughing up blood would indicate hemoptysis. Urinating excessively at night can be indicative of different factors such as taking a diuretic late in the evening causing the client to urinate often at night. This question would be vague. 21
What disease processes contribute to chronic heart failure? Select all that apply. A) Tachydysrhythmias B) Valvular disease C) Pancreatic disease D) Renal failure E) Pulmonary insufficiency
A, B, D Feedback: Hypertension, tachydysrhythmias, valvular disease, cardiomyopathy, and renal failure can contribute to chronic heart failure. Pancreatic disease and pulmonary insufficiency do not contribute to chronic heart failure. 11
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? A) Intubation of the airway B) BP and pulse measurements every 15 to 30 minutes C) Insertion of a central venous catheter D) Hourly administration of a fluid bolus
B Feedback: Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes. 8
You are caring for a client with suspected right-sided heart failure. What would you know that clients with suspected right-sided heart failure may experience? A) Increased urine output B) Gradual unexplained weight gain C) Increased perspiration D) Sleeping in a chair or recliner
B Feedback: Clients with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention. Left-sided heart failure produces paroxysmal nocturnal dyspnea, which may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Right-sided heart failure does not cause increased perspiration or increased urine output. 3
The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse? A) Administer the medication and inform the charge nurse about the rate. B) Withhold the medication and notify the physician of the heart rate. C) Administer atropine to speed the heart rate and then administer the digoxin. D) Administer the medications and then notify the physician.
B Feedback: Digitalis drugs are withheld if the heart rate is less than 60 or more than 120 beats/minute until a physician is consulted. The other choices would have the nurse administer the drug, which would not be the standard of practice. 27
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? A) Decreased urinary output B) Dyspnea on exertion C) Hypotension D) Tachycardia
B Feedback: Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia. 22
A client is taking furosemide (Lasix) for the treatment of heart failure. What food should the nurse suggest that is rich in potassium? A) Pasta B) Peanut butter C) Coffee D) Angel food cake
B Feedback: Peanut butter is rich in potassium and low potassium items are pasta, coffee, and angel food cake. 35
A client in the hospital informs the nurse he "feels like his heart is racing and can't catch his breath." What does the nurse understand occurs as a result of a tachydysrhythmia? A) It causes a loss of elasticity in the myocardium. B) It reduces ventricular ejection volume. C) It increases afterload. D) It increases preload.
B Feedback: Reducing ventricular ejection volume because diastole, during which the ventricle fills with blood (preload), is shortened as a result of a tachydsrhythmia. Causing a loss of elasticity in the muscle is a result of cardiomyopathy. Afterload is decreased not increased. 18
The student nurse is caring for a client with heart failure. Diuretics have been ordered. What method might be used with a debilitated patient to help the nurse evaluate the client's response to diuretics? A) Using mechanical ventilation B) Using a urinary catheter C) Using a pulmonary artery catheter D) Using a biventricular pacemaker
B Feedback: To evaluate response to diuretics, a urinary catheter is used. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. A biventricular pacemaker is used to sustain life. 5
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? A) The development of chronic obstructive pulmonary disease (COPD) B) The development of left-sided heart failure C) The development of right-sided heart failure D) The development of cor pulmonale
B Feedback: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage. 15
A client diagnosed with heart failure has been admitted to the ICU prior to invasive treatment. What treatment could be considered curative for this client? A) Cardiomyoplasty B) External pacemaker placement C) Surgical ventricular restoration D) Ventricular assist device
C Feedback: A procedure known as surgical ventricular restoration (SVR) decreases the size of the heart to a near normal size and shape by removing dysfunctional heart muscle that does not contract properly. Once the adynamic (nonfunctioning) area is removed, the ventricle is repaired with a patch. In the cases that were studied, 91% were free of congestive heart failure after surgery with an ejection fraction that increased from 30% to 40%. A cardiomyoplasty, placement of an external pacemaker, or a ventricular assist device are not considered curative for heart failure. 7
The nurse instructs the client with heart failure to weight themselves at the same time each day using the same scale. When should the client contact the physician? A) If the weight gain is more than 3 lb in 1 week. B) If the weight gain is more than 4 lb in 1 month. C) If the weight gain is more than 2 lb in 24 hours. D) If the weight gain is more than 1 lb in 48 hours.
C Feedback: Check weight at the same time each day using the same scale: consult a physician if you gain more than 2 pounds in 24 hours. The other distractors are not correct since there is a variance with weight on a daily basis.
The nurse is caring for a client in the hospital with chronic heart failure that 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, he becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)? A) Class I (Mild) B) Class II (Mild) C) Class III (Moderate) D) Class IV (Severe)
C Feedback: Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class I is ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken. 14
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? A) The client says that he has been urinating less frequently at night. B) The client says he has been hungry in the evening. C) The client says his rings have become tight and are difficult to remove. D) The client says he is short of breath when ambulating.
C Feedback: Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure. 23
A client with severe mitral valve insufficiency has been admitted to your unit. The client has heart failure and has developed pulmonary edema. What would be the best course of treatment for this client? A) Cardiac glycosides B) Beta-blockers C) Surgery D) Palliative care
C Feedback: If the cause of heart failure and pulmonary edema can be corrected surgically (e.g., a mitral valve disorder), the client is supported medically while being prepared for surgery. Options A, B, and D do not have the potential to reverse or stabilize this client's disease process, so they would not be the best treatment option. 10
A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring? A) Heart rate of 72 beats/minute B) Respiratory rate of 20 breaths/minute C) Blood pressure 80/46 mm Hg D) Oxygen saturation 94%
C Feedback: The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minute is within normal range as well as the blood pressure and oxygen saturation. 19
A client is admitted to the hospital with a diagnosis of heart failure, and the physician orders a BNP level. What results would indicate to the nurse that the client is in moderate heart failure? A) 120 pg/mL B) 400 pg/mL C) 780 pg/mL D) 980 pg/mL
C Feedback: The result of 780 pg/mL indicates that the client has moderate heart failure, 120 pg/mL indicates that the client has heart failure present, 400 pg/mL indicates that the client has mild heart failure, and 980 pg/mL indicates that the client is in severe heart failure. 16
A client is brought to the emergency department via rescue squad with suspicion of cardiogenic pulmonary edema. What complication should the nurse monitor for? Select all that apply. A) Nausea and vomiting B) Pulmonary embolism C) Cardiac dysrhythmias D) Respiratory arrest E) Cardiac arrest
C, D, E Feedback: Pulmonary edema is fluid accumulation in the lungs, which interferes with gas exchange in the alveoli. It represents an acute emergency and is a frequent complication of left-sided heart failure. Cardiac dysrhythmias and cardiac or respiratory arrest are associated complications. Nausea and vomiting are not complications but are symptoms of many disorders. The client is not at increased risk for the development of pulmonary embolism with pulmonary edema. 32
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? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
D Feedback: At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid, shallow breathing. Later, there is a shift to metabolic acidosis as gas exchange becomes more impaired. Respiratory acidosis and metabolic alkalosis are incorrect distractors. 25
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? A) Assess for reduced urine output. B) Assess for reduced blood sodium levels. C) Assess for elevated blood potassium levels. D) Assess for elevated blood urea nitrogen levels.
D Feedback: Elevated blood urea nitrogen indicates impaired renal perfusion in a client with left-sided heart failure. Serum sodium levels may be elevated. Reduced urine output or elevated blood potassium levels do not indicate impaired renal perfusion in a client with left-sided heart failure. 4
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding? A) "Can't walk without becoming short of breath." B) "Has paroxysmal nocturnal dyspnea when walking." C) "Has orthopnea when walking." D) Experiences exertional dyspnea when walking 3 feet; states, "I cannot catch my breath."
D Feedback: Exertional dyspnea is the effort at breathing when active. Answer A is vague and does not give a more detailed explanation for documentation purposes. Orthopnea is the inability to breathe unless sitting upright, and paroxysmal nocturnal dyspnea is being awakened by breathlessness. 20
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client? A) Low-fat diet B) Low-potassium diet C) Low-cholesterol diet D) Low-sodium diet
D Feedback: Medical management of both left-sided and right-sided heart failure is directed at reducing the heart's workload and improving cardiac output primarily through dietary modifications, drug therapy, and lifestyle changes. A low-sodium diet is prescribed, and fluids may be restricted. Because the client will be on a diuretic such as Lasix, he may become potassium depleted and would need potassium in the diet. A low-cholesterol and low-fat diet may be ordered but are not specific to the heart failure. 26
A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate? A) Furosemide (Lasix) B) Nitroglycerin C) Dopamine (Intropin) D) Morphine sulfate
D Feedback: Morphine seems to help relieve respiratory symptoms by depressing higher cerebral centers, thus relieving anxiety and slowing respiratory rate. Morphine also promotes muscle relaxation and reduces the work of breathing. Lasix is a loop diuretic and will decrease fluid accumulation but will not reduce anxiety. Nitroglycerin will promote smooth muscle relaxation in the vessel walls and will relieve pain but not reduce anxiety. Dopamine is an inotrope that will increase the force of ventricular contraction but will not alleviate anxiety. 34
The nurse is preparing to administer furosemide (Lasix) to a client with severe heart failure. What lab study should be of most concern for this client while taking Lasix? A) BNP of 100 B) Sodium level of 135 C) Hemoglobin of 12 D) Potassium level of 3.1
D Feedback: Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These drugs increase sodium and therefore water excretion, but they also increase potassium excretion. If a client becomes hypokalemic, digitalis toxicity is more likely. The BNP does not demonstrate a severe heart failure. Sodium level of 135 is within normal range, as is the hemoglobin level. 28
The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What would be an important instruction for the nurse to give a client who is to undergo a MUGA scan? A) Avoid any activity at least 2 hours before the test. B) Drink plenty of fluids during the test. C) Avoid dairy products a day before and a day after the test. D) Lie very still at intermittent times during the test.
D Feedback: The nurse should instruct the client, who is to undergo a MUGA scan, to lie very still at intermittent times during the 45-minute test. The client need not to drink plenty of fluids, avoid activities before or after the test, or avoid dairy products during the test. 2
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant? A) Implanted cardioverter-defibrillator (ICD) B) Pacemaker C) Intra-aortic balloon pump (IABP) D) Ventricular assist device (VAD)
D Feedback: VADs may be used for one of three purposes: (1) a bridge to recovery, (2) a bridge to transport, or (2) destination therapy (mechanical circulatory support when there is no option for a heart transplant). An implanted cardioverter-defibrillator or pacemaker is not a bridge to transplant and will only correct the conduction disturbance and not the pumping efficiency. An IABP is a temporary, secondary mechanical circulatory pump to supplement the ineffectual contraction of the left ventricle. The IABP is intended for only a few days. 30