UNIT 5- CH29 PrepU w/ rationales
The diagnosis of heart failure is usually confirmed by which of the following? Chest x-ray Echocardiogram Electrocardiogram (12-lead) Ventriculogram
Echocardiogram Explanation: Although the chest X-ray can indicate cardiomegaly and the ECG can indicate a left ventricular abnormality, it is the echocardiogram that is diagnostic. This test measures ejection fraction (EF) which, if greater than 40% and accompanied with signs and symptoms of heart failure, indicates diastolic dysfunction and impaired ventricular relaxation.
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? Intubation of the airway BP and pulse measurements every 15 to 30 minutes Insertion of a central venous catheter Hourly administration of a fluid bolus
Explanation: Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.
A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? No JVD is present. JVD is noted at the level of the sternal angle. JVD is noted 2 cm above the sternal angle. JVD is noted 4 cm above the sternal angle.
JVD is noted 4 cm above the sternal angle. Explanation: JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.
Which is a potassium-sparing diuretic used in the treatment of heart failure? Spironolactone Bumetanide Chlorothiazide Ethacrynic acid
Spironolactone Explanation: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide diuretic. Bumetanide and ethacrynic acid are loop diuretics.
A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals coarse crackles in the lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing decompensated heart failure with pulmonary edema. bilateral pneumonia. acute exacerbation of chronic obstructive pulmonary disease. tuberculosis.
decompensated heart failure with pulmonary edema. Explanation: The production of large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), indicates acute decompensated heart failure with pulmonary edema. These signs can be confused with those of pneumonia and tuberculosis. However, auscultation reveals: coarse crackles, which indicate pulmonary edema. A patient with acute COPD would have diminished lung sounds bilaterally.
A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)? decrease in renal perfusion increased blood volume ejected from ventricle vasodilation of skin dehydration
decrease in renal perfusion Explanation: A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.
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? MRI pulmonary arterial pressure echocardiogram nuclear angiography
echocardiogram Explanation: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. An MRI, pulmonary arterial pressure, and nuclear angiography do not give diagnostic information about the heart's ejection fraction.
Frequently, what is the earliest symptom of left-sided heart failure? dyspnea on exertion anxiety confusion chest pain
dyspnea on exertion Explanation: Dyspnea on exertion is often the earliest symptom of left-sided heart failure.
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." "My feet are bigger than normal." "My pants don't fit around my waist." "I don't have the same appetite I used to."
"I sleep on three pillows each night." Explanation: Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.
The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home? "I eat six small meals a day when I am hungry." "I've stopped eating foods with salt, though I miss the taste." "I'm having trouble going up the steps during the day." "My best time of the day is the morning."
"I'm having trouble going up the steps during the day." Explanation: Difficulty with activities like climbing stairs is an indication of a lessened ability to exercise. Eating small meals and not using salt are usually indicated for clients with heart failure. The client's assertion about morning being the best time of day is a vague statement.
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? Hold any further treatment until the client's blood pressure increases. Notify the health care provider of the chest pain. Administer the third sublingual nitroglycerin tablet. Wait ten minutes after the second tablet to assess pain.
Administer the third sublingual nitroglycerin tablet. Explanation: The nurse will need to administer the third sublingual nitroglycerin tablet. Nitroglycerin is given as three doses for chest pain as the client's blood pressure can tolerate it. The health care provider will be notified after three tablets. The nurse should not hold any further treatment if the client has chest pain. The dosing of nitroglycerin is a five-minute wait.
The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure? Atrial fibrillation First-degree heart block Supraventricular tachycardia Sinus tachycardia
Atrial fibrillation Explanation: Cardiac dysrhythmias such as atrial fibrillation may either cause or result from heart failure; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.
The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? Blood urea nitrogen (BUN) Creatinine Brain natriuretic peptide (BNP) Complete blood count (CBC)
Brain natriuretic peptide (BNP) Explanation: BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.
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. Nausea and vomiting Pulmonary embolism Cardiac arrhythmias Respiratory arrest Cardiac arrest
Cardiac arrhythmias Respiratory arrest Cardiac arrest 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 arrhythmias 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.
Which medication reverses digitalis toxicity? Ibuprofen Warfarin Amlodipine Digoxin immune FAB
Correct response: Digoxin immune FAB Explanation: Digoxin immune FAB binds with digoxin and makes it unavailable for use. The dosage is based on the digoxin concentration and the client's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.
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 experiencing heart failure. The client is going into cardiogenic shock. The client shows signs of aneurysm rupture. The client is in the early stage of right-sided heart failure.
Correct response: The client is going into cardiogenic shock. Explanation: This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenicdf5r4 shock also may cause: cold, clammy skin and generalized weakness, fatigue, and muscle pain (as poor blood flow causes lactic acid to accumulate and prevents waste removal.) Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.
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) Increase in CVP Decrease in blood pressure Absence of cough
Decrease in central venous pressure (CVP) Explanation: A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade.
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? Tachycardia Ascites Nocturia Dizziness
Dizziness Explanation: Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion include dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.
Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure? Decreased central venous pressure Increase in the cardiac index Increased pulmonary artery diastolic pressure Decreased mean pulmonary artery pressure
Increased pulmonary artery diastolic pressure Explanation: Increased pulmonary artery diastolic pressure suggests left-sided heart failure. Central venous pressure increases in heart failure rather than decreases. The cardiac index decreases in heart failure. The mean pulmonary artery pressure increases in heart failure.
The nurse identifies which symptom as a characteristic of right-sided heart failure? Jugular vein distention (JVD) Dyspnea Pulmonary crackles Cough
Jugular vein distention (JVD) Explanation: JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.
Which feature is the hallmark of systolic heart failure? Low ejection fraction (EF) Pulmonary congestion Limited activities of daily living (ADLs) Basilar crackles
Low ejection fraction (EF) Explanation: A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.
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? Low-fat diet Low-potassium diet Low-cholesterol diet Low-sodium diet
Low-sodium diet Explanation: 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.
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. Older adults are at increased risk for cardiac arrests. Older adults are at increased risk for hyperthyroidism. Older adults are at increased risk for asthma.
Older adults are at increased risk for toxicity. Explanation: 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.
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? BNP of 100 Sodium level of 135 Hemoglobin of 12 Potassium level of 3.1
Potassium level of 3.1 Explanation: 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.
Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole? Afterload Preload Ejection fraction Stroke volume
Preload Explanation: Preload is the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from a ventricle. The ejection fraction is the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole. Stroke volume is the amount of blood pumped out of the ventricle with each contraction.
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? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory alkalosis Explanation: 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.
The nurse recognizes which symptom as a classic sign of cardiogenic shock? Restlessness and confusion Hyperactive bowel sounds High blood pressure Increased urinary output
Restlessness and confusion Explanation: Cardiogenic shock occurs when decreased CO leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).
The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer? Digoxin (Lanoxin) Valsartan (Diovan) Metolazone (Zaroxolyn) Carvedilol (Coreg)
Valsartan (Diovan) Explanation: Valsartan (Diovan) is the only angiotensin receptor blocker listed. Digitalis/digoxin (Lanoxin) is a cardiac glycoside. Metolazone (Zaroxolyn) is a thiazide diuretic. Carvedilol (Coreg) is a beta-adrenergic blocking agent (beta-blocker).
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant? Implanted cardioverter-defibrillator (ICD) Pacemaker Intra-aortic balloon pump (IABP) Ventricular assist device (VAD)
Ventricular assist device (VAD) Explanation: VADs may be used for one of three purposes:(1) a bridge to recovery, (2) a bridge to transplant, 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
The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided heart failure? warm extremities ascites resting bradycardia weight loss
ascites Explanation: Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, ascites, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough. Mixed heart failures can have all symptoms of right and left plus cool extremities, resting tachycardia, and weight gain.
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid: canned peas. dried peas. angel food cake. ready-to-eat cereals.
canned peas. Explanation: There is a wide variety of foods that the client can still eat; the key is to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. It is important to read food labels and look for foods that contain less than 300 mg sodium/serving.
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 decreased right ventricular elasticity increased left atrial contractility increased right atrial resistance
decreased left ventricular pumping Explanation: Pulmonary edema is an acute event that results from heart failure. Myocardial scarring, resulting from ischemia, limits the distensibility of the ventricle, making it vulnerable to demands for increased workload. When the demand on the heart increases, there is resistance to left ventricular filling and blood backs up into the pulmonary circulation. Pulmonary edema quickly develops.
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 decreased right ventricular workload decreased peripheral perfusion to the extremities decreased renal perfusion
decreased left ventricular workload Explanation: The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The therapeutic effect is decreased left ventricular workload. The IABP does not change right ventricular workload. The IABP increases perfusion to the coronary and peripheral arteries. The renal perfusion is not affected by IABP.
The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options. Due to the client's high risk for developing Dropdown Item 1 as a result of the prescribed medication, the nurse focuses on monitoring the client for Dropdown Item 2. hypokalemia ventricular arrhythmia hyponatremia nausea hyperuricemia joint swelling
hypokalemia, ventricular arrhythmia Furosemide, a loop diurectic, is often prescribed for clients who experience fluid volume overload due to a diagnosis of heart failure (HF). The client who is newly prescribed furosemide for the treatment of hypervolemia due to HF is at a high risk for developing fluid and electrolyte abnormalites, with a high risk for hypokalemia. Hypokalemia is a potentially life-threatening complication of loop diuretic therapy due to the risk for cardiac arrhythmias. When assessing a client for hypokalemia, the nurse monitors the client for ventricular arrhythmias. This is a priority in the provision of care for a client who is prescribed furosemide for the treatment of heart failure. Although hyponatremia and hyperuricemia are both potential side effects associated with diuretic therapy, they are not high risks for the client who is prescribed furosemide. Although a symptom of hyponatremia is nausea and joint pain is a symptom of hyperuremia, these are not findings that are expected for a client who experiences hypokalemia due to furosemide therapy.
The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion? ascites hepatomegaly inadequate cardiac output nocturia
inadequate cardiac output Explanation: Pulmonary congestion occurs and tissue perfusion is compromised and diminished when the heart, primarily the left ventricle, cannot pump blood out of the ventricle effectively into the aorta and the systemic circulation. Ascites is fluid in the abdomen, not a cause of congestion. Hepatomegaly is an enlarged liver, which does not cause crackling breath sounds. Nocturia, or voiding at night, does not cause crackling breath sounds.
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 diltiazem bumetanide cholestyramine
lisinopril Explanation: Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, beta-blockers, and diuretics such as bumetanide. Many of these medications, particularly ACE inhibitors and beta-blockers, improve symptoms and extend survival. Others, such as diuretics, improve symptoms but may not affect survival. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client? Vasculitis nausea and vomiting Flexion contractures Enlargement of joints
nausea and vomiting Explanation: Digitalis medications are potent and may cause various toxic effects. The nurse should monitor the client for signs of digitalis toxicity, not just during the initial period of therapy, but throughout care management. The most common signs and symptoms include nausea and vomiting which can lead to dehydration and electrolyte imbalance. AND anorexia, visual disturbances, confusion, and bradycardia. Symptoms of toxicity do not include vasculitis, flexion contractures, or enlargement of joints. **The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. A serum digoxin level is obtained if the patient's renal function changes or there are symptoms of toxicity
When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating orthopnea. dyspnea upon exertion. hyperpnea. paroxysmal nocturnal dyspnea.
orthopnea. Explanation: Clients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler position. Dyspnea upon exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.
A nurse suspects that a client has digoxin toxicity. The nurse should assess for: hearing loss. vision changes. decreased urine output. gait instability.
vision changes. Explanation: Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.
A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor? fluid intake and output. urine specific gravity. vital signs. weight.
weight. Explanation: Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.
The nurse instructs a client with heart failure on restricting sodium in the diet. Which client statement indicates that teaching was effective? "I will add a water softener to my water at home." "Food prepared at home is saltless unless I add it while cooking." "Lemon juice and herbs can be used to replace salt when cooking." "Canned vegetables have low sodium content."
"Lemon juice and herbs can be used to replace salt when cooking." Explanation: For the client on a low-sodium or sodium-restricted diet, a variety of flavorings, such as lemon juice, vinegar, and herbs, may be used to improve the taste of the food and facilitate acceptance of the diet. Sodium is contained in municipal water. Water softeners also increase the sodium content of drinking water. Although the major source of sodium in the average American diet is salt, many types of natural foods contain varying amounts of sodium. Even if no salt is added in cooking and if salty foods are avoided, the daily diet will still contain about 2000 mg of sodium. Fresh fruits and vegetables are low in sodium and should be encouraged.
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? A chest x-ray An echocardiogram An electrocardiogram A ventriculogram
An echocardiogram Explanation: Increasing shortness of breath (dyspnea) and fatigue are common signs of left-sided heart failure (HF). However, some of the physical signs that suggest HF may also occur with other diseases, such as renal failure and chronic obstructive pulmonary disease; therefore, diagnostic testing is essential to confirm a diagnosis of HF. Assessment of ventricular function is an essential part of the initial diagnostic workup. An echocardiogram is usually performed to determine the ejection fraction, identify anatomic features such as structural abnormalities and valve malfunction, and confirm the diagnosis of HF.
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? Pulse oximetry Listening to breath sounds End-tidal CO2 Arterial blood gases
Arterial blood gases Explanation: In left-sided heart failure, arterial blood gases may be obtained to assess ventilation and oxygenation.
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? Administer angiotensin II receptor blockers Assess oxygen saturation Administer diuretics Administer angiotensin-converting enzyme inhibitors
Assess oxygen saturation Explanation: The nurse's priority action is to assess oxygen saturation to determine the severity of the exacerbation. It is important to assess the oxygen saturation in a client with heart failure because below-normal oxygen saturation can be life-threatening. Treatment options vary according to the severity of the client's condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve symptoms and reduce the workload on the heart by reducing afterload and preload.
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 Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling
Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours Explanation: Pitting edema is documented as a +1 when a depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options. Due to the client's high risk for developing Dropdown Item 1 as a result of the prescribed medication, the nurse focuses on monitoring the client for Dropdown Item 2. hypokalemia ventricular arrhythmia hyponatremia nausea hyperuricemia joint swelling
Due to the client's high risk for developing hypokalemia as a result of the prescribed medication, the nurse focuses on monitoring the client for ventricular arrhythmia Furosemide, a loop diurectic, is often prescribed for clients who experience fluid volume overload due to a diagnosis of heart failure (HF). The client who is newly prescribed furosemide for the treatment of hypervolemia due to HF is at a high risk for developing fluid and electrolyte abnormalites, with a high risk for hypokalemia. Hypokalemia is a potentially life-threatening complication of loop diuretic therapy due to the risk for cardiac arrhythmias. When assessing a client for hypokalemia, the nurse monitors the client for ventricular arrhythmias. This is a priority in the provision of care for a client who is prescribed furosemide for the treatment of heart failure. Although hyponatremia and hyperuricemia are both potential side effects associated with diuretic therapy, they are not high risks for the client who is prescribed furosemide. Although a symptom of hyponatremia is nausea and joint pain is a symptom of hyperuremia, these are not findings that are expected for a client who experiences hypokalemia due to furosemide therapy.
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? Decreased urinary output Dyspnea on exertion Hypotension Tachycardia
Dyspnea on exertion Explanation: 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.
Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Electrocardiogram (ECG) Echocardiogram Serum electrolytes Blood urea nitrogen (BUN)
Echocardiogram Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.
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? Echocardiogram A pulmonary arteriography A chest radiograph Electrocardiogram
Echocardiogram Explanation: 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.
The nurse is teaching a client about lifestyle modifications after a heart failure diagnosis. What will be included in the teaching? Engage in exercise daily. Restrict dietary potassium. Avoid any alcohol. Drink 3 liters of fluid per day.
Engage in exercise daily. Explanation: Lifestyle recommendations after heart failure include restriction of dietary sodium; avoidance of excessive fluid intake, excessive alcohol intake, and smoking; weight reduction when indicated; and regular exercise. The restriction of potassium is not required. Drinking 3 liters of fluid per day would be excessive for a client with heart failure.
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. Examine the client's joints for crepitus. Examine the client's eyes for excess tears.
Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion. Explanation: During a head-to-toe assessment of a client with CHF, the nurse checks for dyspnea, auscultates apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion. Excess tears are not part of the checklist.
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. Examine the client's joints for crepitus. Examine the client's eyes for excess tears.
Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion. Explanation: During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion. Excess tears are not part of the checklist.
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? The pericardial space is eliminated with scar tissue and thickened pericardium. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.
Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. Explanation: The cardinal signs of cardiac tamponade are falling systolic BP, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).
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? The pericardial space is eliminated with scar tissue and thickened pericardium. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.
Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. Explanation: The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).
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? Weight loss of 0.5 kg (1.1 lbs.) Bilateral lower extremity edema +1 Needs to use a scooter for shopping Fatigue after walking to answer the door
Fatigue after walking to answer the door Explanation: The client's response to activity needs to be monitored. If the client is at home, the degree of fatigue felt after the activity can be used to assess the response. Weight loss is not used to assess activity tolerance but would be helpful to determine the response to medication therapy. Lower extremity edema is not used to assess activity tolerance but would be helpful to determine the response to medication therapy. Tolerance to exercise would be assessed by monitoring heart rate, which should return to baseline within 3 minutes after the activity. Since the client's heart rate returned to baseline in 2 minutes, the activity is being tolerated. Use of a motorized scooter for shopping would not be the best indicator of exercise and/or activity tolerance.
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 30 degrees and legs elevated on pillows Head of the bed elevated 45 degrees and lower arms supported by pillows Supine with arms elevated on pillows above the level of the heart Prone with legs elevated on pillows
Head of the bed elevated 45 degrees and lower arms supported by pillows Explanation: Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the client's weight on the shoulder muscles.
The pathophysiology of pericardial effusion is associated with all of the following except: Increased right and left ventricular end-diastolic pressures. Atrial compression. Increased venous return. Inability of the ventricles to fill adequately.
Increased venous return. Explanation: Venous return is decreased (not increased) with Pericardial effusion because there is an increase in the pericardial fluid, which raises the pressure within the pericardial sac and compresses the heart. Increased right and left ventricular end-diastolic pressures, inability of the ventricles to fill adequately, and atrial compression are all effects of pericardial effusion.
A new client has been admitted with right-sided heart failure. When assessing this client, the nurse knows to look for which finding? Pulmonary congestion Cough Dyspnea Jugular venous distention
Jugular venous distention Explanation: When the right ventricle cannot effectively pump blood from the ventricle into the pulmonary artery, the blood backs up into the venous system and causes jugular venous distention and congestion in the peripheral tissues and viscera. All the other choices are symptoms of left-sided heart failure.
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 Encourage the client to ambulate in room Titrate milrinone rate slowly before discontinuing Teach the client about safe home use of the medication
Monitor blood pressure frequently Explanation: Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to clients with severe HF, including those who are waiting for a heart transplant. Because the drug causes vasodilation, the client's blood pressure is monitored before administration because if the client is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and after infusions of milrinone.
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 Pedal edema Nausea Jugular venous distention
Pulmonary congestion Explanation: When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.
A hospitalized client with heart failure puts on the call light and states, "I've become very short of breath, and I've been coughing up this pink frothy sputum." The nurse immediately suspects which of the following complications? Pulmonary edema Hepatomegaly Decreased renal perfusion pressure Decreased cardiac workload
Pulmonary edema Explanation: When the left ventricle fails, blood backs up into the pulmonary system. Large quantities of frothy sputum, which is sometimes blood-tinged, may be produced, indicating severe pulmonary congestion or pulmonary edema.
A client has been diagnosed with heart failure. What is the major nursing outcome for the client? Reduce the workload on the heart. Walk 30 minutes three times a week. Maintain a healthy diet. Sleep 8 hours per night.
Reduce the workload on the heart. Explanation: Specific objectives of medical management of heart failure include reducing the workload on the heart by reducing preload and afterload. The other choices are objectives that may be supportive of a healthy lifestyle, but are not specific to a client with heart failure.
The nurse recognizes which symptom as a classic sign of cardiogenic shock? Restlessness and confusion Hyperactive bowel sounds High blood pressure Increased urinary output
Restlessness and confusion Explanation: Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).
Which is a manifestation of right-sided heart failure? Accumulation of blood in the lungs Systemic venous congestion Increase in forward flow Paroxysmal nocturnal dyspnea
Systemic venous congestion Explanation: Right-sided heart failure causes systemic venous congestion and a reduction in forward flow. Left-sided heart failure causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues. Some clients with left-sided heart failure get episodes of dyspnea at night, known as paroxysmal nocturnal dyspnea.
The triage nurse in the Emergency Department (ED) is admitting a client with a history of Class III heart failure. What symptoms would the nurse expect the client to exhibit? Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea. The client does not experience any limitation of activity. Ordinary physical activity results in fatigue, heart palpitation, or dyspnea. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.
The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. Explanation: Class III (Moderate)= There is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. This makes options A, B, and D incorrect.
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 that he has been urinating less frequently at night. The client says he has been hungry in the evening. The client says his rings have become tight and are difficult to remove. The client says he is short of breath when ambulating.
The client says his rings have become tight and are difficult to remove. Explanation: 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.
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 chronic obstructive pulmonary disease (COPD) The development of left-sided heart failure The development of right-sided heart failure The development of cor pulmonale
The development of left-sided heart failure Explanation: 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 MI. 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.
The nurse is administering furosemide to a client with heart failure. What best describes the therapeutic action of the medication? Furosemide blocks reabsorption of potassium on the collecting tubule. Furosemide promotes sodium secretion into the distal tubule. The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels. The medication promotes potassium secretion into the distal tubule and constrict renal vessels.
The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels. Explanation: Loop diuretics such as furosemide blocks sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. Furosemide also dilate renal vessels. Although loop diuretics block potassium reabsorption, this isn't a therapeutic action. Thiazide diuretics, not loop diuretics, promote sodium secretion into the distal tubule.The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the
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 first heart sound (S1). a third heart sound (S3). a fourth heart sound (S4). a murmur.
a third heart sound (S3). Explanation: An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.
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? right-sided heart failure. acute pulmonary edema. pneumonia. cardiogenic shock.
acute pulmonary edema. Explanation: Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, JVD, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.
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 oliguria S4 ventricular gallop sign decreased O2 saturation levels
pitting edema Explanation: The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response. Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a thickened left ventricle, seen with aortic stenosis or hypertension. The decreased oxygen saturation levels are from hypoxemia.
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? hypertension high urine output dry mucous membranes pulmonary crackles
pulmonary crackles Explanation: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.
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 myocardial infarction. pulmonary embolism. pneumonia. pulmonary edema.
pulmonary embolism. Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.
