420: Test 1 part B
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for: 1. Intermittent claudication. 2. Dyspnea. 3. Dependent edema. 4. Crackles.
3. Dependent edema. Right-sided heart failure causes venous congestion resulting in such symptoms as peripheral (dependent) edema, splenomegaly, hepatomegaly, and neck vein distention. Intermittent claudication is associated with arterial occlusion. Dyspnea and crackles are associated with pulmonary edema, which occurs in left-sided heart failure.
A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. What other client presentation increases the likelihood of a cardiovascular disorder? 1. clubbing of fingers 2. urinary frequency 3. irritability 4. lower substernal abdominal pain
1. clubbing of fingers Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, palpitations, fainting, fatigue, and peripheral edema. Clubbing of fingers indicates chronic hypoxemia, possibly as a result of undiagnosed heart disease. Urinary frequency is a symptom of a UTI or other urinary tract issue. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders.
The nurse is instructing a client who is at risk for peripheral artery disease how to use knee-length elastic stockings (support hose). What instructions should the nurse include in the teaching plan? Select all that apply. 1. Apply the elastic stockings before getting out of bed. 2. Remove the stockings if swelling occurs. 3. Remove the stockings every 8 hours, elevate the feet, and reapply in 15 minutes. 4. Once the stockings have been pulled over the calf, roll the remaining stocking down to make a cuff. 5. Keep the stockings in place for 48 hours, and reapply using a clean pair of stockings.
1. Apply the elastic stockings before getting out of bed. 3. Remove the stockings every 8 hours, elevate the feet, and reapply in 15 minutes. Elastic stockings (support hose) are used to promote circulation by preventing pooling of blood in the feet and legs. The stockings should be applied in the morning before the client gets out of bed. The stockings should be applied smoothly to avoid wrinkles, but the top should not be rolled down to avoid constriction of circulation. The stockings should be removed every 8 hours and the client should elevate the legs for 15 minutes and reapply the stockings. Clean stockings should be applied daily or as needed.
The nurse is providing discharge instructions to the client with peripheral vascular disease. The nurse should include which information in the discussion with this client? Select all that apply. 1. Avoid prolonged standing and sitting. 2. Limit walking so as not to activate the "muscle pump." 3. Keep extremities elevated on pillows. 4. Keep the legs in a dependent position. 5. Use a heating pad to promote vasodilation.
1. Avoid prolonged standing and sitting. 3. Keep extremities elevated on pillows. Elevating the extremities counteracts the forces of gravity and promotes venous return and reduces venous stasis. Walking is encouraged to activate the muscle pump and promote collateral circulation. Prolonged sitting and standing lead to venous stasis and should be avoided. Although heat promotes vasodilation, use of a heating pad is to be avoided to reduce the risk of thermal injury secondary to diminished sensation.
A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and their family to expect which common symptom that typically resolves spontaneously? 1. depression 2. ankle edema 3. memory lapses 4. dizziness
1. Depression For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves without medical intervention. However, the nurse should advise family members that symptoms of depression don't always resolve on their own. They should make sure they recognize worsening symptoms of depression and know when to seek care. Ankle edema seldom follows CABG surgery and may indicate right-sided heart failure. Because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, an abnormal condition following CABG surgery. This symptom warrants immediate physician notification.
What is the major goal of nursing care for a client with heart failure and pulmonary edema? 1. Increase cardiac output. 2. Improve respiratory status. 3. Decrease peripheral edema. 4. Enhance comfort.
1. Increase cardiac output. Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.
When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply. 1. Take and record daily pulse rate. 2. Avoid air travel because of airport security alarms. 3. Immobilize the affected arm for 4 to 6 weeks. 4. Avoid using a microwave oven. 5. Avoid lifting anything heavier than 3 lb (1.36 kg).
1. Take and record daily pulse rate. 5. Avoid lifting anything heavier than 3 lb (1.36 kg). The nurse must teach the client how to take and record the pulse daily. The client should be instructed to avoid lifting the operative-side arm above shoulder level for 1 week post insertion. It takes up to 2 months for the incision site to heal and full range of motion to return. The client should avoid heavy lifting until approved by the health care provider (HCP). The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function.
When the nurse is collaborating with the health care team to care for a client who has decreased arterial blood flow to the lower extremity, which goals would be most appropriate? Select all that apply. 1. The extremities are warm to touch. 2. The client demonstrates improvement in respiratory status. 3. Muscle pain with activity has decreased. 4. The client participates in self-care. 5. There are no signs of ulcer formation.
1. The extremities are warm to touch. 3. Muscle pain with activity has decreased. 5. There are no signs of ulcer formation. The temperature of the involved lower extremity is an important outcome for a client with peripheral vascular disease. The temperature will indicate the degree to which the blood supply is getting to the extremity. Warmth indicates adequate blood supply. Pain is an indication of ischemia and lack of oxygen that results when the oxygen demand becomes greater than the supply. Therefore, a decrease in pain would indicate that oxygen is being delivered to the tissues. With adequate tissue perfusion, there are no signs of ulcer formation. Improvement in respiratory status is not an outcome of improving arterial blood flow. The ineffective tissue perfusion has not disrupted the client's ability to provide self-care. Although the client may be able to provide self-care with less pain, this outcome is not a direct result of improved tissue perfusion related to interruption of arterial blood flow.
After administering prescribed medications to clients, which client requires immediate intervention? 1. a client taking digoxin who has a morning potassium level of 3.0 mEq/L 2. a client taking atenolol who has a heart rate of 58 3. a client with a nitroglycerine patch who has a headache 4. a client taking captopril who has a nonproductive cough
1. a client taking digoxin who has a morning potassium level of 3.0 mEq/L The client's low potassium level increases the risk for digoxin toxicity and potential dysrhythmias. Digoxin inhibits the action of the sodium-potassium pump that moves sodium and potassium across the cell membrane and slows the electrical impulses through the atrioventricular node. This leads to a rapid reduction of the remainder of potassium ions available for the "pump" action, which can cause a buildup of toxic serum levels of digoxin. Digoxin toxicity can cause many types of cardiac dysrhythmias due to the increased intracellular calcium release and decreased AV conduction time slowing the heart rate. The nurse should notify the healthcare provider about the potassium level to prevent toxicity from occurring. The other clients are experiencing expected effects of the prescribed medication.
Three days after mitral valve replacement surgery, the client tells the nurse there is a "clicking" noise coming from the chest incision. The nurse's response should reflect the understanding that the client may be experiencing which of the following? 1. anxiety related to altered body image 2. anxiety related to altered health status 3. altered tissue perfusion 4. lack of knowledge regarding the postoperative course
1. anxiety related to altered body image Verbalized concerns from this client may stem from their anxiety over the changes their body has gone through after open heart surgery. Although the client may experience anxiety related to the altered health status or may have a lack of knowledge regarding the postoperative course, the client is pointing out the changes in their body image. The client is not concerned about altered tissue perfusion.
Which assessment data should a nurse use to monitor the respiratory status of a client with pulmonary edema? 1. arterial blood gas (ABG) analysis 2. pulse oximetry 3. skin color assessment 4. lung sounds
1. arterial blood gas (ABG) analysis ABG analysis is the best measure for determining the extent of hypoxia caused by pulmonary edema and for monitoring the effects of therapy. Although a nurse can use any of the options to detect pulmonary changes, assessment of skin color and assessment of lung fields commonly are subject to interpretation by practitioners. The use of pulse oximetry is unreliable, especially in the case of severe vasoconstriction as is present in pulmonary edema.
An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. During admission, what should the nurse assess first? 1. blood pressure 2. skin breakdown 3. serum potassium level 4. urine output
1. blood pressure It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and when the nurse obtains a complete health history, the nurse should inspect the client's skin for any signs of breakdown; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.
The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which are expected findings on assessment? Select all that apply. 1. decreased cardiac output 2. increased heart rate 3. vasoconstriction in skin, GI tract, and kidneys 4. decreased pulmonary perfusion 5. fluid overload
1. decreased cardiac output 2. increased heart rate 3. vasoconstriction in skin, GI tract, and kidneys 5. fluid overload Heart failure can be a result of several cardiovascular conditions, which will affect the heart's ability to pump effectively. The body attempts to compensate through several neurohormonal mechanisms. Decreased cardiac output stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the heart rate and contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process resulting in the release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure, and therefore cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary disease.
The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock? 1. dopamine 2. enalapril 3. furosemide 4. metoprolol
1. dopamine Cardiogenic shock is when the heart has been significantly damaged and is unable to supply enough blood to the organs of the body. Dopamine, a sympathomimetic drug, improves myocardial contractility and blood flow through vital organs by increasing perfusion pressure. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and does not have a direct effect on contractility or tissue perfusion. Metoprolol is a adrenergic blocker that slows heart rate and lowers blood pressure; neither is a desired effect in the treatment of cardiogenic shock.
Which signs and symptoms accompany a diagnosis of pericarditis? 1. fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) 2. low urine output secondary to left ventricular dysfunction 3. lethargy, anorexia, and heart failure 4. pitting edema, chest discomfort, and nonspecific ST-segment elevation
1. fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. Low urine output secondary to left ventricular dysfunction lethargy, anorexia, heart failure and pitting edema, result from acute renal failure.
A client has a coxsackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for which health problem? 1. myocarditis 2. myocardial infarction 3. renal failure 4. liver failure
1. myocarditis Intracellular microorganisms, such as viruses and parasites, invade the myocardium to survive. These microorganisms damage the vital organelles and cause cell death in the myocardium. The myocardium becomes weak, leading to heart failure; then T lymphocytes invade the myocardium in response to the viral infection. The T lymphocytes respond to the viral infection by secreting cytokines to kill the virus, but they also kill the virus-infected myocardium. Myocardial infarction, renal failure, and liver failure are not direct consequences of a viral or parasitic infection.
A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah's Witness, the client declares in their advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for the nurse caring for the client to: 1. realize the surgeon has the right to refuse to care for the client. 2. advise the surgeon to arrange for an alternate cardiac surgeon. 3. tell the client that they can donate their own blood for the procedure. 4. inform the client that their decision could shorten their life.
1. realize the surgeon has the right to refuse to care for the client. Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn't acceptable to the client. It isn't the responsibility of the surgeon to find an alternate. Jehovah's Witnesses don't believe in receiving blood transfusions. Informing the client that their decision can shorten their life is inappropriate in that the statement may be inaccurate and it ignores the client's right of autonomy.
A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal? 1. potassium 2. B-type natriuretic peptide (BNP) 3. C-reactive protein (CRP) 4. platelet count
2. B-type natriuretic peptide (BNP) The client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.
A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs? 1. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to reduce secretion of aldosterone and antidiuretic hormone. 2. Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. 3. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to increase aldosterone secretion. 4. Low blood pressure triggers the baroreceptors to decrease sympathetic nervous system stimulation.
2. Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. In the early stage of heart failure, low blood pressure triggers baroreceptors in the carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing an increased heart rate, vasoconstriction, and increased myocardial oxygen consumption. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to increase, not reduce, secretion of aldosterone and antidiuretic hormone, causing sodium and water retention and arterial vasoconstriction.
The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? 1. oxygen saturation level 2. arterial blood gas (ABG) findings 3. red blood cells (RBCs) and hemoglobin count findings 4. white blood cell differential
2. arterial blood gas (ABG) findings Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Oxygen saturation levels are usually affected by hypoxemia but cannot be used to diagnose acid-base imbalances such as metabolic acidosis.
A nurse is caring for a client with a history of cardiac disease and type 2 diabetes. The nurse is closely monitoring the client's blood glucose level. Which medication is the client most likely taking? 1. procainamide 2. carvedilol 3. amiodarone 4. diltiazem hydrochloride
2. carvedilol The nurse must monitor blood glucose levels closely in clients with type 2 diabetes who are taking beta-adrenergic blockers such as carvedilol, because beta-adrenergic blockers may mask the signs of hypoglycemia. The nurse should monitor QRS duration in clients taking procainamide and pulmonary function in clients taking amiodarone (because the drug may cause pulmonary fibrosis). Diltiazem may cause an increased PR interval or bradycardia.
A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. What other sign should the nurse assess next? 1. hyperkalemia. 2. digoxin toxicity. 3. fluid deficit. 4. pulmonary edema.
2. digoxin toxicity. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.
Which should be the nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease? 1. decrease anxiety 2. enhance myocardial oxygenation 3. administer sublingual nitroglycerin 4. educate the client about their symptoms
2. enhance myocardial oxygenation Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration is not the first priority. Although educating the client and decreasing anxiety are import in care delivery, neither is a priority when a client is compromised.
A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume? 1. semi-Fowler's l 2. leaning forward while sitting 3. supine 4. prone
2. leaning forward while sitting The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action and therefore don't relieve chest pain associated with pericarditis.
A nurse is assessing a client with aortic stenosis. The nurse expects to hear a murmur that is: 1. high-pitched and blowing. 2. loud and rough during systole. 3. low-pitched, rumbling during diastole. 4. low-pitched and blowing.
2. loud and rough during systole. An aortic murmur is loud and rough and is heard over the aortic area. The murmur in aortic insufficiency is high-pitched and blowing and is heard at the third or fourth intercostal space at the left sternal border. Mitral stenosis has a low-pitched rumbling murmur heard at the apex. Mitral insufficiency has a high-pitched, blowing murmur at the apex. There is no condition that has a low-pitched, blowing murmur.
A client with angina shows the nurse the nitroglycerin tablets that the client carries in a plastic bag in a pocket. Where should the nurse teach the client to keep the nitroglycerin tablets? 1. in the refrigerator 2. in a cool, moist place 3. in a dark container to shield from light 4. in a plastic pill container where it is readily available
3. in a dark container to shield from light Nitroglycerin in all dosage forms (sublingual, transdermal, or intravenous) should be shielded from light to prevent deterioration. The client should be instructed to keep the nitroglycerin in the dark container that is supplied by the pharmacy, and it should not be removed or placed in another container.
What instruction should the nurse's discharge teaching plan for the client with heart failure include? 1. maintaining a high-fiber diet 2. walking 2 miles (3.2 km) every day 3. obtaining daily weights at the same time each day 4. remaining sedentary for most of the day
3. obtaining daily weights at the same time each day Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the health care provider (HCP) if there has been a weight gain of 2 lb (0.91 kg) or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an exercise program for the client, such as walking 2 miles (3.2 km) every day, would not be appropriate at discharge. The client's exercise program would need to be planned in consultation with the HCP and based on the history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not prescribe an exercise program for the client, a sedentary lifestyle should not be recommended.
A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances? 1. early defibrillation in cases of atrial fibrillation 2. cardioversion in cases of atrial fibrillation 3. pacemaker placement 4. early defibrillation in cases of ventricular fibrillation
4. early defibrillation in cases of ventricular fibrillation AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association and Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a tool to increase sudden cardiac arrest survival rates.
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? 1. "I sleep on three pillows each night." 2. "My feet are bigger than normal." 3. "My pants don't fit around my waist." 4. "I don't have the same appetite I used to."
1. "I sleep on three pillows each night." 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.
After the client has a temporary pacemaker inserted, the nurse should verify documentation on the medical record about which information? 1. the client's cardiovascular status 2. the client's emotional state 3. the type of sedation used 4. pacemaker rate, type, and settings
1. the client's cardiovascular status The cardiovascular status of the client is the first information documented and will validate the effectiveness of the temporary pacemaker. The client's emotional state and the type of sedation are important but not a high priority. The nurse will need to document the pacemaker information (settings of the pacemaker); this will be considered part of the cardiovascular information.
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). The nurse should document this as: 1. a first heart sound (S1). 2. a third heart sound (S3). 3. a fourth heart sound (S4). 4. a murmur.
2. a third heart sound (S3). 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 is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? 1. jugular vein distention 2. right upper quadrant pain 3. bibasilar crackles 4. dependent edema
3. bibasilar crackles Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
A fourth heart sound (S4) indicates a: 1. dilated aorta. 2. normally functioning heart. 3. decreased myocardial contractility. 4. failure of the ventricle to eject all blood during systole.
4. failure of the ventricle to eject all blood during systole. An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. A nurse hears decreased myocardial contractility as a third heart sound. A nurse doesn't hear an S4 in a normally functioning heart.
A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis? 1. race 2. age 3. history of diabetes mellitus 4. history of aortic valve replacement
4. history of aortic valve replacement A heart valve prosthesis such as an aortic valve replacement is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren't major risk factors for infective endocarditis.
A client has been diagnosed with atrial fibrillation. The health care provider prescribed warfarin to be taken on a daily basis. The nurse instructs the client to avoid using which over-the-counter medication while taking warfarin? aspirin diphenhydramine digoxin pseudoephedrine
Aspirin Aspirin is an antiplatelet medication. The use of aspirin is contraindicated while taking warfarin because it will potentiate the drug's effects. Diphenhydramine and pseudoephedrine do not affect blood coagulation. Digoxin is not an over-the-counter medication; it requires a prescription.
Before administering digoxin, a nurse reviews information about the drug. She learns that after digoxin is metabolized, the body eliminates remaining digoxin as unchanged drug by way of the: lungs. kidneys. feces. skin.
kidneys After digoxin is metabolized, the kidneys eliminate remaining digoxin as unchanged drug. Therefore, a client with renal dysfunction will require a decreased digoxin dosage. Although some drugs may be eliminated by other routes, digoxin isn't known to be eliminated by way of the lungs, feces, or skin.
Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? 1. 5 to 10 minutes 2. 30 to 60 minutes 3. 2 to 4 hours 4. 6 to 8 hours
1. 5 to 10 minutes After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.
What is the nurse's priority action for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention? 1. Reposition the client so the lower legs dangle off the bed. 2. Apply supplemental oxygen at 4 L/min. 3. Administer furosemide 40 mg I.V. as ordered. 4. Notify the attending physician.
1. Reposition the client so the lower legs dangle off the bed. The client's presentation suggests congestive heart failure. Cardiac output is compromised. Dangling the legs will cause pooling of blood in the lower extremities, allowing some relief to the overloaded heart. Oxygenation will improve with improved cardiac output. Furosemide will decrease the fluid, but will take some time to work. Notifying the attending should occur after the client is rescued.
The nurse is caring for a client following a myocardial infarction and is aware that complications can occur due to damage to the myocardium. Which interventions would be appropriate for this client? Select all that apply. 1. electrocardiogram with any chest pain 2. continuous cardiac monitoring via telemetry 3. ambulating length of hall in first 24 hours 4. maintaining bed rest for 72 hours 5. auscultating apical pulse every 2 hours
1. electrocardiogram with any chest pain 2. continuous cardiac monitoring via telemetry 5. auscultating apical pulse every 2 hours After a myocardial infarction, it is important to monitor the client carefully for complications. An EKG should be done with any chest pain to assess for any changes that would indicate additional damage to the heart muscle. Auscultating the apical pulse and continuous cardiac monitoring would identify a change in status. Bed rest would be maintained for 24 hours, and ambulation would be added gradually, not in the first 24 hours.
A client is admitted with heart failure and pulmonary edema. To help alleviate respiratory distress, the nurse should perform which actions? Select all that apply. 1. Place a pillow under both legs. 2. Elevate head of bed to 90 degrees. 3. Administer diuretics as ordered. 4. Encourage deep breathing and coughing. 5. Prepare for modified postural drainage.
2. Elevate head of bed to 90 degrees. 3. Administer diuretics as ordered. Elevating the head of the bed allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Diuretics are administered to a client with heart failure and pulmonary edema to decrease the fluid buildup in the lungs and decrease the workload of the heart. Placing a pillow under the legs would not correct shortness of breath. The client could not tolerate a position for postural drainage based on the current respiratory status.
A client with left-sided heart failure complains of 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: 1. right-sided heart failure. 2. acute pulmonary edema. 3. pneumonia. 4. cardiogenic shock.
2. acute pulmonary edema. 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, jugular vein distention, 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.
What should a nurse expect to find while assessing the vital signs of a client who has abruptly stopped taking beta-adrenergic blocker? 1. abnormally low blood pressure 2. irregular pulse 3. increased respiratory rate 4. decreased respiratory rate
2. irregular pulse Abrupt withdrawal of a beta-adrenergic blocker results in rebound cardiac excitation, which causes ventricular arrhythmias and an irregular pulse. Abnormally low blood pressure would be unlikely because beta-adrenergic blockers are used to treat hypertension. Abrupt withdrawal of this medication wouldn't directly affect a client's respiratory rate.
The nurse is teaching a client about actions to control manifestations of left-sided heart failure. Which statement by the client indicates appropriate understanding? 1. "I will notify my doctor if I gain 1 pound (0.5 kg) in 24 hours." 2. "I will use my nitroglycerin tablets if my pulse rises to 90/min." 3. "If I have trouble breathing, I will sit in my recliner with my head up." 4. "If I have leg edema I will wear elastic stockings at night."
3. "If I have trouble breathing, I will sit in my recliner with my head up." The decreased cardiac output that results from left-sided heart failure causes blood to accumulate in the pulmonary system. This produces pulmonary edema and difficulty breathing when lying flat. Weight gain is common with heart failure, but small fluctuations are normal with routine intake and output of food and fluids. Therefore clients are not expected to report a weight change unless it is more than 3 pounds (1.4 kg) in 48 hours. Nitroglycerin tablets are used to treat angina, not a rapid pulse. Elastic stockings may help control peripheral edema, but they do not help left-sided heart failure.
A nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse should anticipate using: 1. antiembolism stockings. 2. oxygen. 3. diuretics. 4. anticoagulants.
3. diuretics. Diuretics, such as furosemide, reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don't decrease fluid volume excess.
The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which electrolyte imbalance? 1. hyponatremia 2. hypocalcemia 3. hyperkalemia 4. hypermagnesemia
3. hyperkalemia Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor. Hyperkalemia can be a side effect of ACE inhibitors. Because of this side effect, ACE inhibitors should not be administered with potassium-sparing diuretics.
The nurse is caring for a client with a third heart sound. Which action is indicated? 1. Place the client flat in bed. 2. Place the client on a cardiac monitor. 3. Observe for sluggish skin turgor. 4. Assess the client's lungs for crackles.
4. Assess the client's lungs for crackles. A third heart sound indicates fluid volume excess (FVE) or heart failure; crackles are an additional finding and will further refine the assessment. Placing the client with FVE or heart failure flat in bed may cause respiratory distress by decreasing expansion. A cardiac monitor will determine heart rhythm, but it will not give information related to FVE. Sluggish skin turgor is a sign of fluid volume deficit or dehydration.
Which are indications that a client with a history of left-sided heart failure is developing pulmonary edema? Select all that apply. 1. distended jugular veins 2. dependent edema 3. anorexia 4. coarse crackles 5. tachycardia
4. coarse crackles 5. tachycardia Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.
The nurse is caring for a client in the coronary care unit when the cardiac monitor reveals ventricular fibrillation. The nurse should anticipate which intervention? 1. an I.V. push of digoxin 2. an I.V. line for emergency medications 3. immediate defibrillation 4, synchronized cardioversion
3. immediate defibrillation When ventricular fibrillation is verified, the first intervention is defibrillation, which is the only intervention that will terminate this lethal dysrhythmia. Digoxin is not indicated for V-fib. An I.V. will be one of the priorities, but not first. The client would need to have a functional rhythm for synchronized cardioversion to be performed.
A client with acute pulmonary edema has been taking an angiotensin-converting enzyme (ACE) inhibitor. The nurse explains that this medication has been ordered to 1. promote diuresis. 2. increase cardiac output. 3. decrease contractility. 4. reduce blood pressure.
4. reduce blood pressure. ACE inhibitors are given to reduce blood pressure by inhibiting aldosterone production, which in turn decreases sodium and water reabsorption. ACE inhibitors also reduce production of angiotensin II, a potent vasoconstrictor. Diuretics are given to increase urine production. Vasodilators increase cardiac output. Negative inotropic agents decrease contractility.
A physician admits a client with a history of I.V. drug abuse to the medical-surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this client has: 1. retrosternal pain that worsens during supine positioning. 2. pulsus paradoxus. 3. a scratchy pericardial friction rub. 4. Osler's nodes and splinter hemorrhages.
4. Osler's nodes and splinter hemorrhages. Infective endocarditis occurs when an infectious agent enters the bloodstream, such as from I.V. drug abuse or during an invasive procedure or dental work. Typical assessment findings in clients with this disease include Osler's nodes (red, painful nodules on the fingers and toes), splinter hemorrhages, fever, diaphoresis, joint pain, weakness, abdominal pain, a new or altered heart murmur, and Janeway's lesions (small, hemorrhagic areas on the fingers, toes, ears, and nose). Retrosternal pain that worsens when the client is supine, pulsus paradoxus, and pericardial friction rub are common findings in clients with pericarditis, not infective endocarditis.
A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? 1. magnesium level of 2.5 mg/dl (0.1 mmol/L) 2. calcium level of 7.5 mg/dl (0.4 mmol/L) 3. sodium level of 152 mEq/L (152 mmol/L) 4. potassium level of 3.1 mEq/L (3.1 mmol/L)
4. potassium level of 3.1 mEq/L (3.1 mmol/L) Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? 1. phytonadione (vitamin K) 2. protamine sulfate 3. thrombin 4. plasma protein fraction
2. protamine sulfate Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.
A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant? 1. croup 2. rheumatic fever 3. severe staphylococcal infection 4. medullary sponge kidney
2. rheumatic fever Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, may eventually lead to hypertension but doesn't damage heart structures.
The nurse is administering an IV potassium chloride supplement to a client who has heart failure. What should the nurse consider when developing a plan of care for this client? 1. Hyperkalemia will intensify the action of the client's digoxin preparation. 2. The client's potassium levels will be unaffected by a potassium-sparing diuretic. 3. The administration of the IV potassium chloride should not exceed 10 mEq/h or a concentration of 40 mEq/L. 4. Metabolic alkalosis will increase the client's serum potassium levels.
3. The administration of the IV potassium chloride should not exceed 10 mEq/h or a concentration of 40 mEq/L. When administering IV potassium chloride, the administration should not exceed 10 or a concentration of 40 via a peripheral line. These limits are extremely important to prevent the development of hyperkalemia and the possibility of cardiac dysrhythmias. In some situations, with dangerously low serum potassium levels, the client may need cardiac monitoring and more than 10 mEq (mmol/L) of potassium per hour. Potassium-sparing diuretics may lead to hyperkalemia because they affect the kidney's ability to excrete excess potassium. Metabolic alkalosis can cause potassium to shift into the cells, thus decreasing the client's serum potassium levels. Hypokalemia can lead to digoxin toxicity.
A client is started on digoxin. The health care provider (HCP) prescribes IV push doses of 0.5 mg now, 0.25 mg in 8 hr., and another 0.25 mg in another 8 hr. The client has a 1,000 mL bag of normal saline infusing at 25 mL/hr. What action should the nurse perform? 1. Add the medication to the fluid remaining in the IV bag of solution. 2. Infuse each dose over 30 minutes using an IV piggyback set-up. 3. Question the HCP about the dosing and frequency of the prescription. 4. Administer each dose of medication over 5 minutes via IV push.
4. Administer each dose of medication over 5 minutes via IV push. Digoxin is a potent cardiovascular drug that both slows conduction and increases contractility of the heart. Digoxin is administered slowly via IV push. Although each 1 mL can be diluted in 4 mL of SW, NS, D5W, or LR for injection, it is not added to the IV bag of solution or given over a 30-minute duration. There is no need to question the HCP's prescription at this time. Because digoxin is a new medication for this client and because it takes this type of dosing to reach a therapeutic level, dosing such as the one described is typical when the medication is first initiated. It is a type of loading dose protocol and for digoxin, sometimes referred to as digitalization.
A client arrives at the emergency department with severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. Suddenly, the client collapses and becomes unresponsive. What is the priority action by the nurse? 1. Activate the emergency response team. 2. Initiate ventilations before chest compressions. 3. Maintain an open airway. 4. Initiate chest compressions before ventilations.
4. Initiate chest compressions before ventilations. This is according to current standards by the American heart and stroke associations (Heart and Stroke Foundation of Canada). The other choices are all in sequence at some point of resuscitation, but current standards are to initiate chest compression, then ventilation.
