AH2 Heart NCLEX

The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

1. "Chest pain is caused by decreased oxygen to the heart muscle." Rationale: 1. This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain. 2. This is the explanation in medical terms that should not be used when explaining medical conditions to a client. 3. This explains congestive heart failure but does not explain why chest pain occurs. 4. Respiratory compromise occurs when the lungs cannot oxygenate the blood, such as occurs with altered level of consciousness, cyanosis, and increased respiratory rate.

The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan.

1. An elevated B-type natriuretic peptide (BNP). Rationale: 1. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF. 2. An elevated CK-MB would indicate a myocardial infarction, not severe CHF. CK-MB is an isoenzyme. 3. A positive D-dimer would indicate a pulmonary embolus. 4. A positive ventilation/perfusion (V/Q) scan (ratio) would indicate a pulmonary embolus.

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

1. Apical pulse rate of 110 and 4+ pitting edema of feet. Rationale: 1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status. 2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing. 3. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored breathing, not eupnea, which means normal breathing. 4. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status.

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct the client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to a counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

1. Encourage a low-fat, low-cholesterol diet. 2. Instruct the client to walk 30 minutes a day. 4. Refer to a counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet. rationale: 1. A low-fat, low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries. 2. Walking will help increase collateral circulation. 3. Salt should be restricted in the diet of a client with hypertension, not coronary artery disease. 4. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. 5. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system.

The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct the client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor.

1. Instruct the client to keep a diary of activity, especially when having chest pain. rationale: 1. The Holter monitor is a 24-hour electrocardiogram, and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity. 2. The Holter monitor should not be removed for any reason. 3. All medications should be taken as prescribed. 4. The client should perform all activity as usual while wearing the Holter monitor so the HCP can get an accurate account of heart function during a 24-hour period.

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. Rationale: 1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation. 2. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation. 3. A pulse oximeter reading of greater than 93% is considered normal. 4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure.

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."

2. "I should bake or grill any meats I eat." Rationale: 1. According to the American Heart Association, the client should not eat more than three (3) eggs a week, especially the egg yolk. 2. The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat. 3. The client should drink low-fat milk, not whole milk. 4. Pork products (bacon, sausage, ham) are high in sodium, which is prohibited in a low-salt diet, not a low-cholesterol, low-fat diet.

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client.

2. Assess the client's neurovascular status. Rationale: 1. The client's right leg should be kept straight to prevent arterial bleeding from the femoral insertion site for the catheter used to perform the catheterization. 2. The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor. 3. The head of the bed should be elevated no more than 10 degrees. The client should be kept on bedrest, flat with the affected extremity straight, to help decrease the chance of femoral artery bleeding. 4. The gag reflex is assessed if a scope is inserted down the trachea (bronchoscopy) or esophagus (endoscopy) because the throat is numbed when inserting the scope. A catheter is inserted in the femoral or brachial artery when performing a cardiac catheterization.

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

2. Assess the client's serum potassium level. rationale: 1. The nurse should always assess the apical (not radial) pulse, but the pulse is not affected by a loop diuretic. 2. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication. 3. The glucometer provides a glucose level, which is not affected by a loop diuretic. 4. The pulse oximeter reading evaluates peripheral oxygenation and is not affected by a loop diuretic.

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

2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. Rationale: 1. The client with peripheral edema will experience calf tightness but would not have leg cramping, which is the result of low potassium levels. The timing of the diuretic will not change the side effect of leg cramping resulting from low potassium levels. 2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium. 3. Weight gain is monitored in clients with CHF, and elevating the legs would decrease peripheral edema by increasing the rate of return to the central circulation, but these interventions would not help with leg cramps. 4. Ambulating frequently and performing leg-stretching exercises will not be effective in alleviating the leg cramps.

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.

2. Stop the activity immediately and rest. rationale: 1. The client should take the coronary vasodilator nitroglycerin sublingually, but it is not the first intervention. 2. Stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain). 3. The client should keep a diary of when angina occurs, what activity causes it, and how many nitroglycerin tablets are taken before chest pain is relieved. 4. If the chest pain (angina) is not relieved with three (3) nitroglycerin tablets, the client should call 911 or have someone take him to the emergency department. Notifying the HCP may take too long.

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

2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct the client to remove the saltshaker from the dinner table. Rationale: 1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day. 2. The client should not take digoxin if the radial pulse is less than 60. 3. The client should be on a low-sodium diet to prevent water retention. 4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase with diuretics. 5. Instruct the client to take the diuretic in the morning to prevent nocturia.

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking the medication with food.

2. Teach the client how to prevent orthostatic hypotension. Rationale: 1. If a cough develops, the client should notify the health-care provider because this is an adverse reaction and the HCP will discontinue the medication. 2. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored. 3. ACE inhibitors may cause the client to retain potassium; therefore, the client should not increase potassium intake. 4. An ACE inhibitor should be taken one (1) hour before meals or two (2) hours after a meal to increase absorption of the medication.

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.

2. The client has an apical pulse of 56. Rationale: 1. This blood pressure is normal and the nurse would administer the medication. 2. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate. 3. A headache will not affect administering the medication to the client. 4. The potassium level is within normal limits, but it is usually not monitored prior to administering a beta blocker.

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? 1. The client will be able to ambulate in the hall by date of discharge. 2. The client will have an audible S1 and S2 with no S3 heard by end of shift. 3. The client will turn, cough, and deep breathe every two (2) hours. 4. The client will have a SaO2 reading of 98% by day two (2) of care.

2. The client will have an audible S1 and S2 with no S3 heard by end of shift. Rationale: 1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis. 2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure, which could be life threatening. 3. This is a nursing intervention, not a short-term goal, for this client. 4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output.

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays (CXRs)?" 3. "Are you sexually active?" 4. "Have you had any weight change?"

3. "Are you sexually active?" rationale: 1. Bowel movements are important, but they are not pertinent to coronary artery disease. 2. Chest x-rays are usually done for respiratory problems, not for coronary artery disease. 3. Sexual activity is a risk factor for angina resulting from coronary artery disease. The client's being elderly should not affect the nurse's assessment of the client's concerns about sexual activity. 4. Weight change is not significant in a client with coronary artery disease.

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40°F. 4. Wear open-toed shoes when ambulating.

3. Do not walk outside if it is less than 40°F. rationale: 1. Isometric exercises are weight lifting-type exercises. A client with CAD should perform isotonic exercises, which increase muscle tone, not isometric exercises. 2. The client should walk at least 30 minutes a day to increase collateral circulation. 3. When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside. 4. The client should wear good, supportive tennis shoes when ambulating, not sandals or other open-toed shoes.

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

3. The 75-year-old client scheduled for a cardiac catheterization. rationale: 1. This client is at high risk for complications related to necrotic myocardial tissue and will need extensive teaching, so this client should not be assigned to a new graduate. 2. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate. 3. A new graduate should be able to complete a preprocedure checklist and get this client to the catheterization laboratory. 4. Chest pain means this client could be having a myocardial infarction and should not be assigned to a new graduate.

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention.

3. The client is able to perform ADLs without dyspnea. Rationale: 1. Pitting edema changing from 3+ to 4+ indicates a worsening of the CHF. 2. The client's ability to take the radial pulse would evaluate teaching, not medical treatment. 3. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs. 4. Any jugular vein distention indicates that the right side of the heart is failing, which would not indicate effective medical treatment.

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain on inspiration and a nonproductive cough.

3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62 rationale: 1. This client is stable because discharge is scheduled for the following day. Therefore, this client does not need to be assigned to the most experienced registered nurse. 2. This client is more in need of custodial nursing care than care from the most experienced registered nurse. Therefore, the charge nurse could assign a less experienced nurse to this client. 3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client. 4. These complaints usually indicate muscular or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration. This client does not require the care of an experienced nurse as much as does the client with signs of shock.

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

4. "If my chest pain is not gone with one tablet, I will go to the ER." Rationale: 1. If the tablets are not kept in a dark bottle, they will lose their potency. 2. The tablets should burn or sting when put under the tongue. 3. The client should keep the tablets with him in case of chest pain. 4. The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911.

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

4. Assist the client to a sitting position. Rationale: 1. Sponging dry the client's forehead would be appropriate, but it is not the first intervention. 2. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention. 3. Taking the vital signs would be appropriate, but it is not the first intervention. 4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead.

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)g sodium diet. 3. Weigh the client daily. 4. Plan for frequent rest periods.

4. Plan for frequent rest periods. rationale: 1. Measuring the intake and output is an appropriate intervention to implement for a client with CHF, but it does not address getting the client to tolerate activity. 2. Dietary sodium is restricted in clients with CHF, but this is an intervention for decreasing fluid volume, not for increasing tolerance for activity. 3. Daily weighing monitors fluid volume status, not activity tolerance. 4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome.

A client with a history of myocardial infarctions tells the nurse that he has been smoking for 35 years and it does not matter now if he stops. What should the nurse respond to this client? A) "Your risk of continued coronary heart disease will decrease by half when you stop." B) "It will enhance the effects of your medications." C) "It will reduce your risk of lung cancer." D) "It will decrease any complications you might develop."

A) "Your risk of continued coronary heart disease will decrease by half when you stop." Rationale: Smoking cessation reduces the risk for coronary heart disease by 50% no matter how long the person has smoked. It will reduce lung cancer, decrease complications, and possibly enhance medication effects, but the primary focus for this client is the effect on coronary heart disease.

The nurse is planning care for several clients. Which client has the greatest risk of developing heart failure? A) A 69-year-old African-American male with hypertension B) A 50-year-old African-American female who smokes C) A 75-year-old Caucasian male who is overweight D) A 52-year-old Caucasian female with asthma

A) A 69-year-old African-American male with hypertension Rationale: Age, race, and hypertension lead to an increased risk for developing heart failure. Race and smoking are risk factors, but being female and younger decreases the overall risk. Age and obesity are risk factors, but not as much as age, being African-American, and having hypertension. Asthma is not considered a significant risk factor in the development of heart failure.

An older client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be indicated for this client? A) Beta blocker B) Digoxin C) Nitrate medications D) Fluids

A) Beta blocker Rationale: Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Nitrates should be avoided because they increase blood pressure. Digoxin should be avoided because it increases the force of contractions. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.

During an assessment, a client with congestive heart failure and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care? A) Excess Fluid Volume related to shortness of breath B) Ineffective Family Management of Therapeutic Regime related to inability to purchase medications C) Fatigue related to shortness of breath D) Activity Intolerance related to shortness of breath

A) Excess Fluid Volume related to shortness of breath Rationale: The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications should be addressed after the client's physiological problems are resolved.

An older client is diagnosed with dilated cardiomyopathy. What will the nurse most likely assess in this client? Select all that apply. A) Fatigue B) Lower extremity edema C) Syncope D) Dyspnea E) Jugular vein distention

A) Fatigue B) Lower extremity edema D) Dyspnea E) Jugular vein distention Rationale: Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity edema, shortness of breath or dyspnea, and jugular vein distention. Disorders of the heart valve, arrhythmias, and blood clots may occur with disease progression. Syncope is not a manifestation of dilated cardiomyopathy.

A nurse caring for clients with heart failure must be aware of the compensatory mechanisms activated in heart failure. Which physiology is not associated with the neuroendocrine compensatory mechanism? A) Increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate. B) Decreased CO stimulates the sympathetic nervous system and catecholamine release. C) Decreased CO and decreased renal perfusion stimulate the renin-angiotensin system. D) Antidiuretic hormone is released from posterior pituitary.

A) Increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate Rationale: When the heart begins to fail, mechanisms are activated to compensate for the impaired function and maintain the cardiac output. The primary compensatory mechanisms are as follows: 1. The Frank-Starling mechanism 2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system 3. Myocardial hypertrophy The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine response.

A client diagnosed with systolic heart failure is admitted to the Intensive Care Unit (ICU). The nurse assigned to this client understands that systolic heart failure: A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system. B) Results when the heart cannot completely relax in diastole, disrupting normal filling. C) Decreases passive diastolic filling, increasing the importance of atrial contraction to preload. D) Results from decreased ventricular compliance caused by hypertrophic and cellular changes and impaired relaxation of the heart muscle.

A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system. Rationale: Heart failure is commonly classified as either systolic or diastolic heart failure, based on the underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system. All other choices are true of diastolic heart failure, not systolic.

The nurse is positioning a client with left-sided heart failure in bed. Which sleeping position would the client find the most comfortable? A) Seated in a recliner with 2-3 pillows under feet B) Lying on the left side with the head of the bed elevated 30° C) Seated in a recliner with 2-3 pillows under head D) Lying on either side with the head of the bed elevated 30°

A) Seated in a recliner with 2-3 pillows under feet Rationale: The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary congestion and decreased cardiac output. Being in an upright position will ease the work of breathing. Side-lying positions will not help alleviate or prevent the development of orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent edema, but 2-3 pillows are not needed for sleep.

A nurse is caring for a client with cardiomyopathy who has a nursing diagnosis of Activity Intolerance. The nurse plans all interventions except: A) Spacing out nursing activities so client fatigue is lessened. B) Assisting with client ADLs as necessary. C) Using passive and active range-of-motion (ROM) exercises as tolerated. D) Consulting with a physical therapist on an activity plan.

A) Spacing out nursing activities so client fatigue is lessened. Rationale: The client who is experiencing activity intolerance should have nursing interventions implemented that encourage and preserve client energy. Assisting the client with ADLs, utilizing ROM exercises, and consulting with physical therapy are all interventions which support this nursing diagnosis. The nurse should cluster nursing activities, not space them out, in order to conserve client energy.

A nurse is caring for a client who has been successfully resuscitated after a myocardial infarction. The client has now developed an arrhythmia. The nurse understands that the causes of this arrhythmia are all of the following except: A) Tissue alkalosis. B) Cellular acidosis. C) Electrolyte imbalance. D) Hypoxia.

A) Tissue alkalosis. Rationale: Cellular acidosis, electrolyte imbalances, and hypoxia affect impulse conduction and myocardial contractility. The risk for dysrhythmias increases, and myocardial contractility decreases, reducing stroke volume, cardiac output, blood pressure, and tissue perfusion.

The nurse is assessing a client being treated for congestive heart failure. What physical findings would indicate that the client's condition is not improving? Select all that apply. A) Urine output 160 ml over 8 hours B) Pulse oximetry reading of 96% C) Temperature of 98.6°F (37°C) D) Wheezing of breath sounds in all lobes E) Moderate amount of clear, thin mucus

A) Urine output 160 ml over 8 hours D) Wheezing of breath sounds in all lobes Rationale: Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. These sounds would indicate that the client's condition is not improving. A urine output of less than 30 ml/hour should be reported to the healthcare provider and is an indication of a worsening of congestive heart failure. A temperature reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings.

The nurse is providing discharge teaching about a cardiac diet to a client following a myocardial infarction. Which client statement indicates that the​ nurse's teaching has been​ successful? (Select all that apply.​) A. "I am going to have a roast beef sandwich for​ lunch." B. ​"I don't like vegetable oil​ spread, so I will seek a different healthy butter​ alternative." C. "As soon as I get out of​ here, I'm going to my favorite steakhouse to​ celebrate!" D. ​"I will continue cooking my food in coconut oil because of its many health​ benefits." E. "I am happy that I​ won't have to give up my almond butter​ sandwiches!"

A. "I am going to have a roast beef sandwich for​ lunch." B. ​"I don't like vegetable oil​ spread, so I will seek a different healthy butter​ alternative." E. "I am happy that I​ won't have to give up my almond butter​ sandwiches!" Rationale: Clients with coronary artery disease​ (CAD) should reduce their consumption of saturated fats and cholesterol and should increase fiber intake. The goal is to lower the​ client's low-density lipoprotein​ (LDL). Roast beef is a lean cut of meat and therefore is appropriate in moderation. Almonds are high in​ fiber, and almond butter and peanut butter are full of monounsaturated​ fats, which are recommended to be a​ client's source of fat. Coconut oil and red​ meat, like​ steak, are high in saturated fat and should be avoided. Clients should be encouraged to find alternatives to their favorite foods that work with their prescribed diet.

A client who has a strong family history of coronary artery disease asks the​ nurse, "How can I decrease my chances of developing problems with my​ arteries?" Which response by the nurse is​ appropriate? (Select all that​ apply.) A. "Keeping your blood pressure within normal levels will decrease the risk of injury to your​ arteries." B. "You can reduce your risk by making some changes in your​ lifestyle, such as moderate​ exercise." C. "There is little you can do except take medication to prevent coronary artery​ disease." D. "A diet high in​ fruits, vegetables, and unsaturated fatty acids may help protect your​ arteries." E. ​"As long as your cholesterol is​ normal, your arteries will remain​ clear."

A. "Keeping your blood pressure within normal levels will decrease the risk of injury to your​ arteries." B. "You can reduce your risk by making some changes in your​ lifestyle, such as moderate​ exercise." D. "A diet high in​ fruits, vegetables, and unsaturated fatty acids may help protect your​ arteries." ​Rationale: The causes of atherosclerosis are not​ known, but research has shown a connection with modifiable risk factors such as​ cholesterol, triglycerides, lack of​ exercise, smoking,​ obesity, blood​ pressure, diet,​ stress, and diabetes. Elevated cholesterol is only one of the factors that can contribute to the development of plaque in the arteries. Excessive pressures within the arterial system can cause injury to the arterial endothelium. Endothelial damage promotes platelet adhesion and aggregation and attracts leukocytes to the area. Risk factors such as​ age, gender, and heredity cannot be modified. The exact cause is​ unclear, but it is believed that​ fruits, vegetables, whole​ grains, and unsaturated fatty acids have nutrients that help protect the arteries from injury.

The nurse is assessing a client who has a possible myocardial infarction​ (MI). Which finding is consistent with this​ diagnosis? (Select all that​ apply.) A. Anxiety B. Tachypnea C. ST segment depression D. Vomiting E. Q wave changes

A. Anxiety B. Tachypnea D. Vomiting E. Q wave changes Rationale: Clinical manifestations of a myocardial infarction ​ (MI) include​ tachypnea, anxiety,​ vomiting, and electrocardiogram​ (ECG) changes in the Q wave. A client experiencing an MI would experience ST segment​ elevation, not depression.

A client has constant crushing chest pain rated at 9 out of 10 that began 30 minutes ago and is increasing in intensity. The nurse should recognize the client is at risk for which​ disorder? A. Myocardial infarction​ (MI) B. Stable angina C. Coronary artery disease​ (CAD) D. Atherosclerosis

A. Myocardial infarction​ (MI) ​Rationale: Stable angina is the predictable form of chest pain that occurs when the heart is exerted or is exposed to cold or stress. In this​ case, the angina is​ unstable, and therefore the client is at increased risk for MI. Atherosclerosis is a​ long-term illness that would not cause the increasing pain and intensity described by the client. CAD is the cause of chest pain but is not a disorder that develops as a result of it.

A community care nurse is providing education to a group of adults regarding myocardial infarction (MI). When discussing ways to decrease the number of MI-related deaths, the nurse will include all of the following statements except: A) "It is important to learn how to perform cardiopulmonary resuscitation (CPR) techniques." B) "Be sure to take a baby aspirin every day to help prevent an MI." C) "Increase your knowledge of cardiac health and cardiac-related disease." D) "Seek immediate medical attention when you suspect an MI."

B) "Be sure to take a baby aspirin every day to help prevent an MI." Rationale: When educating clients regarding ways to decrease the number of MI-related deaths, the nurse will stress the importance of prevention. Learning about cardiac health and cardiac disease, as well as learning CPR, is appropriate. Clients should be taught to seek immediate medical attention when they suspect an MI. However, instructing all clients to take a baby aspirin every day to help prevent an MI is inappropriate, as not all clients should take this medication.

A nurse is educating a client with cardiomyopathy about diet choices which are appropriate for the client's condition. The nurse will include all statements except: A) "It is important to monitor your sodium intake." B) "Increasing your dietary protein helps with cardiac cell repair." C) "Here is a list of high-fat, high-cholesterol foods to avoid." D) "I have notified the dietitian regarding your condition in order to provide you with more information."

B) "Increasing your dietary protein helps with cardiac cell repair." Rationale: Diet is an important part of long-term management of heart failure. It also contributes to reducing fluid retention. The nurse will instruct the client with cardiomyopathy to monitor sodium intake and to avoid high-fat, high-cholesterol food. Instructing the client to increase protein is not appropriate and is not shown effective in managing cardiomyopathy. Consulting with the dietitian is appropriate with this client.

A nurse is providing discharge education to a client who has been diagnosed with angina. Which statement would the nurse exclude from teaching? A) "Stable angina is the most common form of angina." B) "Prinzmetal angina is atypical angina that occurs with strenuous exercise." C) "Unstable angina occurs with increasing frequency, severity, and duration." D) "Clients with unstable angina are at risk for a heart attack."

B) "Prinzmetal angina is atypical angina that occurs with strenuous exercise." Rationale: Angina results from ischemia and can be a one-time event or a chronic condition. There are three types of angina: stable, unstable, and Prinzmetal. Stable angina is the most common form of angina and is relieved with rest and nitrate medications. Unstable angina occurs with increasing frequency, severity, and duration. Clients with unstable angina are at risk for a heart attack, or myocardial infarction.

A client with angina complains that the pain is prolonged and severe, and occurs at the same time each day while at rest. There are no precipitating factors to the pain. How should the nurse describe this type of angina pain? A) Non-anginal pain B) Atypical angina (Prinzmetal angina) C) Unstable angina D) Stable angina

B) Atypical angina (Prinzmetal angina) Rationale: Atypical or Prinzmetal angina often occurs at the same time each day and typically at rest. Stable angina is induced by exercise and is relieved by rest or nitroglycerin. Unstable angina is not relieved by rest or nitroglycerin and is less predictable. The client has been diagnosed with angina, and, therefore, the pain the client is experiencing is angina.

An elderly female client complains of fatigue, nausea, intermittent chest discomfort, and not sleeping well. What should the nurse suspect this client is experiencing? A) Pancreatic disease B) Cardiac disease C) Normal changes of aging D) Signs of anemia

B) Cardiac disease Rationale: Many elderly women complain of vague symptoms when having a myocardial infarction including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present pain in the abdominal region. These symptoms are not considered normal changes of aging. Anemia would present with fatigue but not with nausea or chest discomfort.

A client is prescribed metoprolol for a heart disorder. What should the nurse teach the client about this medication? A) Expect a rapid heart rate. B) Change positions slowly. C) Reduce protein intake. D) Increase fluids.

B) Change positions slowly. Rationale: Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly since this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. The client should not be instructed to increase fluids. Protein restriction is not indicated with this medication.

A client recovering from an acute myocardial infarction is prescribed aspirin. What should the nurse instruct the client about this medication? Select all that apply. A) Report any itching after seven days of taking. B) Check with your healthcare provider before taking herbal remedies. C) Take at a different time of day than warfarin. D) Report bleeding or bruising to the healthcare provider. E) Do not skip any scheduled appointments to have blood drawn for labs.

B) Check with your healthcare provider before taking herbal remedies. D) Report bleeding or bruising to the healthcare provider. Rationale: Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can increase the effect of the aspirin. Aspirin inhibits platelet aggregation and clot formation. Bleeding and bruising can occur, and should be reported to the healthcare provider. Itching is not a common side effect of aspirin therapy. Aspirin and Coumadin are not to be taken concurrently. No lab appointments will be made just for aspirin therapy.

An older client diagnosed with cardiomyopathy reports having to rest between activities during the day. What should the nurse realize is the reason for this client's fatigue? A) Increased stroke volume B) Decreased cardiac output C) An elongated and dilated aorta D) Increased blood pressure

B) Decreased cardiac output Rationale: Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium. Rest could be required after each activity that puts physiological stress on the heart. Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and this has a direct effect on the activity level that can be tolerated. It is unknown if the client has high blood pressure, an elongated and dilated aorta, or increased stroke volume.

The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem? A) Cluster activities. B) Instruct on deep breathing. C) Medications appropriate to increase heart rate D) Positioning to increase blood return

B) Instruct on deep breathing. Rationale: The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Clustering activities would negatively impact oxygenation. Periods of rest should occur between activities. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart would include Trendelenburg, which would negatively impact oxygenation.

The nurse is instructing an older client about atorvastatin (Lipitor) to treat elevated cholesterol. What side effects should the nurse advise the client to report to the healthcare provider? A) Headaches B) Muscle pain and weakness C) Bruising and excessive bleeding D) Shortness of breath

B) Muscle pain and weakness Rationale: Side effects of statin drugs, such as atorvastatin (Lipitor), include liver inflammation, elevated enzymes, and muscle pain and weakness. Clients are to be advised to report these symptoms while on these medications. The other symptoms are unrelated to statin drugs.

The nurse is planning care for an infant with congestive heart failure. What should the nurse include in this child's care? A) Give larger feedings less often to conserve energy. B) Organize activities to allow for uninterrupted sleep. C) Monitor respirations during active periods. D) Force fluids appropriate for age.

B) Organize activities to allow for uninterrupted sleep. Rationale: It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the heart. Fluids should be restricted to those that are high in calories and low in volume in order to avoid overloading the lungs with fluid. Respirations are difficult to monitor during active periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.

During hospitalization for congestive heart failure, a client awakens during the night frightened and short of breath. What is this client most likely experiencing? A) Cardiomyopathy B) Paroxysmal nocturnal dyspnea C) High-output failure D) Multisystem heart failure

B) Paroxysmal nocturnal dyspnea Rationale: Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing multisystem heart failure, cardiomyopathy, or high-output failure.

The nurse is instructing a client on lifestyle changes to prevent the onset of heart disease. What should be included in this teaching? Select all that apply. A) Limit exercise to 15 minutes a day. B) Reduce saturated fats in the diet. C) Avoid cigarette smoking. D) Wear elastic hose. E) Limit fluid intake.

B) Reduce saturated fats in the diet. C) Avoid cigarette smoking. Rationale: Interventions that would help the client prevent the onset of cardiovascular disease would be to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids and wearing elastic hose are not known to prevent the onset of cardiovascular disease. Fifteen minutes of exercise a day may not be enough exercise to prevent the onset of cardiovascular disease.

Which client reaction should the nurse expect during a coronary artery​ spasm? A.Gradual increase in peripheral edema B.Sudden onset of acute chest pain C.Acute reduction in level of consciousness D.Gradual increase in systolic blood pressure

B.Sudden onset of acute chest pain Rationale: The nurse should expect a sudden onset of acute chest pain from a coronary artery​ spasm, which is characteristic of Prinzmetal​ angina, in which there is an acute reduction in coronary blood flow. An acute reduction in level of consciousness indicates neurologic involvement. A gradual increase in peripheral edema is a sign of heart failure. A gradual increase in systolic blood pressure can have multiple causes.

A client with angina is experiencing acute chest pain. What actions would the nurse implement at this time? Select all that apply. A) Administer antianxiety medication as prescribed. B) Coach in non-pharmacological pain management techniques. C) Keep on bed rest. D) Administer morphine sulfate 2 mg intravenous push as prescribed. E) Administer oxygen at 2 liters/minute via nasal cannula as prescribed.

C) Keep on bed rest. D) Administer morphine sulfate 2 mg intravenous push as prescribed. E) Administer oxygen at 2 liters/minute via nasal cannula as prescribed. Rationale: Interventions for the client experiencing acute chest pain include administering oxygen as prescribed, keeping on bed rest, and administering morphine sulfate as prescribed. Non-pharmacologic pain management techniques are not appropriate for an episode of acute chest pain. Antianxiety medications are not effective in acute chest pain.

The nurse instructor is teaching a group of student nurses regarding the various layers of the heart. Which statements will the nurse include? Select all that apply. A) "The endocardium covers the entire heart and great vessels." B) "The endocardium is the muscular layer of the heart that contracts during each heartbeat." C) "The outermost layer of the heart is the epicardium." D) "The myocardium consists of myofibril cells." E) "The myocardium has four layers."

C) "The outermost layer of the heart is the epicardium." D) "The myocardium consists of myofibril cells." Rationale: The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.

A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating, and fatigued with routine care activities. The nurse would identify which of the following nursing diagnoses as being appropriate for this client? A) Imbalanced Nutrition: Less than Body Requirements B) Deficient Knowledge C) Activity Intolerance D) Self-Care Deficit

C) Activity Intolerance Rationale: The client is short of breath with ambulation and eating, and fatigued with routine care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time. There is not enough information to determine if the client has a knowledge deficit. Shortness of breath with meals does not indicate that the client has Imbalanced Nutrition. Fatigue with routine care activities does not necessarily mean that the client has a Self-Care Deficit.

The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with cardiomyopathy. Which interventions should the nurse emphasize when planning this client's care? Select all that apply. A) Monitor brain natriuretic peptide (BNP) level. B) Provide oxygen as prescribed. C) Assess respiratory status and lung sounds every 4 hours and as needed. D) Provide information about activity upon discharge. E) Monitor intake and output.

C) Assess respiratory status and lung sounds every 4 hours and as needed. E) Monitor intake and output. Rationale: Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output. Providing oxygen and monitoring BNP level are interventions appropriate for the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of Activity Intolerance.

A client with cardiomyopathy is experiencing tachycardia. Which medication order does the client's nurse anticipate? A) ACE Inhibitor B) Angiotensin II receptor blocker C) Beta blocker D) Cardiac glycoside

C) Beta blocker R A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the heart rate. ACE inhibitors and angiotensin II blockers are used to decrease blood pressure in a client with cardiomyopathy. Cardiac glycosides are used in congestive heart failure and do not assist in lowering the heart rate in a client with cardiomyopathy.

A client tells the nurse that he knows he has high blood pressure but does not want to take any medication. Which health problem is the client at risk of developing? A) Gastritis B) Diabetes C) Cardiomyopathy D) Metabolic syndrome

C) Cardiomyopathy Rationale: Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not been associated with metabolic syndrome, diabetes, or gastritis.

A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease. The nurse will include all except: A) Dilated. B) Restrictive. C) Hypotrophic. D) Arrythmogenic right ventricular.

C) Hypotrophic. Rationale: The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right ventricular, and unclassified.

A client with heart failure is admitted to the hospital for the placement of an implantable defibrillator. The client appears comfortable at rest but displays dyspnea with ADLs. In which stage of heart failure does the nurse classify this client? A) I B) II C) III D) IV

C) III Rationale: This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is comfortable at rest but displays dyspnea with less than normal physical activity. Also in this stage, surgical intervention includes implantation of a defibrillator.

A client, admitted with irregular chest pain and shortness of breath, complains of fatigue with activity. The client's body mass index (BMI) is 30.5. Which nursing diagnosis would be a priority for the client at this time? A) Ineffective Coping B) Fear C) Imbalanced Nutrition: More than Body Requirements. D) Fluid Volume Deficit

C) Imbalanced Nutrition: More than Body Requirements. Rationale: The client with a BMI of 30.5 is obese. In addition, the client has irregular chest pain and shortness of breath, and complains of fatigue with activity. The priority nursing diagnosis for the client at this time would be Imbalanced Nutrition: More than Body Requirements. Fear and Ineffective Coping would be applicable to the client diagnosed with an acute myocardial infarction. There is no evidence that the client has Fluid Volume Deficit.

A nurse is caring for a client suspected of a cocaine-induced myocardial infarction. Cocaine may cause a myocardial infarction because the drug: A) Significantly increases the serum triglyceride level, leading to the development of an atheroma. B) Alters the body's clotting mechanisms, leading to thrombus formation. C) Increases sympathetic nervous system stimulation, increasing blood pressure and vasoconstriction. D) Alters electrolyte balance, leading to arrhythmias.

C) Increases sympathetic nervous system stimulation, increasing blood pressure and vasoconstriction. Rationale: Acute myocardial infarction may also develop as a result of cocaine intoxication. Cocaine increases sympathetic nervous system activity by both increasing the release of catecholamines from central and peripheral stores and interfering with the reuptake of catecholamines. This increased catecholamine concentration stimulates the heart rate and increases its contractility, increases the automaticity of cardiac tissues and the risk of dysrhythmias, and causes vasoconstriction and hypertension. The other answers do not occur with cocaine intoxication.

A client is prescribed enalapril (Vasotec) for treatment of heart failure. What assessment finding should cause the nurse concern following the initial administration of this drug? A) Serious rash B) Ototoxicity C) Low blood pressure D) Irregular pulse

C) Low blood pressure Rationale: Severe hypotension can occur after the initial administration of enalapril (Vasotec). Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and an irregular pulse are adverse effects of beta blockers.

A client with cardiomyopathy receiving diuretic therapy has a urine output of 300 cc in 8 hours. What should the nurse do to assist this client? A) Assist the client to ambulate. B) This is a normal urine output and the client does not need anything. C) Notify the physician, as the client could be dehydrated. D) Measure abdominal girth as a true assessment of the client's fluid status.

C) Notify the physician, as the client could be dehydrated. Rationale: The nurse should notify the physician, because a urine output of 300 cc in 8 hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. This is not a normal urine output. The nurse should not assist the client out of bed to ambulate at this time. Daily weights are an objective measurement of fluid volume and not abdominal girth.

A client is admitted with complaints of lower extremity edema and occasional shortness of breath. Which electrocardiogram finding supports that the client is at risk for an alteration in perfusion? A) P wave smooth and round B) Absent U wave C) PR interval 0.30 seconds D) ST segment isoelectric

C) PR interval 0.30 seconds Rationale: The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The ST segment should be isoelectric. The U wave is not normally seen.

What will the nurse most likely assess in a client with right heart failure? A) Leg cramps B) Indigestion C) Reduced circulation to the pulmonary structures D) Reduced urine output

C) Reduced circulation to the pulmonary structures Rationale: Circulation to the pulmonary structures begins with the right side of the heart. The client with right heart failure will have reduced circulation to these structures. There is no evidence to suggest that right heart failure will cause indigestion or reduced urine output. Not all clients with right heart failure experience leg cramps.

A nurse is caring for a client with heart failure secondary to an acute non-cardiac condition. Which condition would be excluded from the client's cause of heart failure? A) Massive pulmonary embolus B) Hyperthyroidism C) Rheumatic fever D) Volume overload

C) Rheumatic fever Rationale: Heart failure is caused by either impaired myocardial function, increased cardiac workload, or acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary embolus, hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired myocardial function.

The nurse is preparing preoperative teaching for an older client scheduled for a ventricular assist device. What should the nurse include in these instructions? A) Need to stay on bed rest for a week or more B) Cardiac pain postoperatively is to be expected. C) Risk for postoperative infection D) Expect to be ambulating the evening of surgery.

C) Risk for postoperative infection Rationale: Clients with VAD are at considerable risk for infection; strict aseptic technique is used with all invasive catheters and dressing changes. The client may or may not be on bed rest for a week or more after the surgery. The client, however, will most likely not be ambulating the evening of the surgery. Cardiac pain postoperatively is not to be expected and could indicate a myocardial infarction.

The nurse is providing care to a client who has experienced several episodes of angina. What is the primary outcome for this client? A) The client will experience relief of chest pain with therapeutic lifestyle changes. B) The client will experience relief of chest pain with aspirin therapy. C) The client will experience relief of chest pain with nitrate therapy. D) The client will experience relief of chest pain with anticoagulant therapy.

C) The client will experience relief of chest pain with nitrate therapy. Rationale: A primary goal in the treatment of angina is to reduce the intensity and frequency of angina episodes. Rapid-acting organic nitrates are the drugs of choice for terminating an acute angina episode. Anticoagulant therapy is used to prevent additional thrombi from forming post-myocardial infarction; it will not relieve angina pain. Therapeutic lifestyle changes are significant if the client is to maintain a healthy heart, but they will not relieve chest pain; this is accomplished with medications. Aspirin therapy following an acute myocardial infarction dramatically reduces mortality due to its antiplatelet function; it will not relieve angina pain.

The nurse is teaching a client about coronary artery disease​ (CAD). Which response by the client indicates the need for further​ teaching? A. "It is a leading cause of death for men and women in the United​ States." B. "The increased levels of​ high-density lipoproteins decrease the risk of​ atherosclerosis." C. "It decreases quality of life but does not increase a​ person's risk of​ death." D. "Damage to the linings of my arteries can cause clots and​ blockage."

C. "It decreases quality of life but does not increase a​ person's risk of​ death." Rationale: Coronary artery disease is a leading cause of death for men and women in the United States. A lack of oxygenated blood to the coronary arteries will decrease a​ client's ability to function and increase their risk of death.​ High-density lipoproteins attract​ cholesterol, returning it from peripheral tissues to the liver. Endothelial damage causes the body to send platelets to seal the area and leukocytes to fight inflammation. These protective mechanisms also contribute to the formation of fibrous plaque. Fibrous plaque protrudes into the arterial lumen and invades the muscular media layer of the vessel as well as the inner wall of the intima. This results in a decreased ability of the vessel to dilate.

The nurse is preparing a bulletin board regarding lifestyle changes to prevent coronary artery disease. Which information should the nurse​ include? (Select all that apply.​) A. During​ menopause, women see a decrease in HDL levels and an increase in​ low-density lipoprotein​ (LDL) levels. B. Family history of CAD is a strong indicator for the development of​ heart-related problems. C. Walk for 30 minutes five or six times a week to lower LDL and triglycerides and to raise HDL levels. D. Diabetes affects the tissue that lines the blood​ vessels, making way for diseases like atherosclerosis. E. Stopping smoking will increase​ high-density lipoprotein​ (HDL) levels and help prevent the development of coronary artery disease​ (CAD).

C. Walk for 30 minutes five or six times a week to lower LDL and triglycerides and to raise HDL levels. E. Stopping smoking will increase​ high-density lipoprotein​ (HDL) levels and help prevent the development of coronary artery disease​ (CAD). ​Rationale: Stopping smoking and walking for 30 minutes several times a week represents modifiable risk factors for CAD. Clients can make lifestyle changes in these areas to decrease their risk for developing CAD. Smoking cessation improves HDL levels and lowers LDL levels and also improves the viscosity of​ blood, so clients should be encouraged to quit smoking. Regular physical exercise lowers very​ low-density lipoprotein​ (VLDL), LDL, and triglyceride​ levels, and it raises HDL levels. Clients are encouraged to participate in 30 minutes of exercise five or six times a week. While understanding about menopause and its associated symptoms is​ important, it is not information that can be used to effectively change the risk of CAD. Family history is not modifiable and cannot help with needed lifestyle changes. Although understanding the effects of diabetes is also​ important, it is not an effect of lifestyle change to decrease the risk of CAD.

A client diagnosed with cardiomyopathy is being discharged to home. What client statement indicates discharge teaching has been effective? A) "I will exercise as much as possible, regardless of feeling weak and short of breath." B) "My pants getting tight around the waist, means I'm eating too much and should cut back on food." C) "I will eat foods containing sodium only if drinking water with them." D) "I will see the physician to discuss implanting a cardiac defibrillator next week."

D) "I will see the physician to discuss implanting a cardiac defibrillator next week." Rationale: Evidence that discharge instruction is effective for a client with cardiomyopathy would be the statement "I will see the physician to discuss implanting a cardiac defibrillator next week," as sudden cardiac death can occur with this medical diagnosis. The other client statements would indicate that discharge teaching was not effective and the client needs additional instruction and follow-up.

The nurse is preparing teaching for a client with hypertrophic cardiomyopathy. For which medication classification should the nurse prepare to instruct this client? A) Digitalis B) Vasodilators C) Nitrates D) Beta blocker

D) Beta blocker Rationale: Beta blockers are the drugs of choice to reduce anginal symptoms and syncopal episodes associated with hypertrophic cardiomyopathy. Vasodilators, digitalis, and nitrates are contraindicated for the client with hypertrophic cardiomyopathy.

When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the: A) family history of coronary artery disease. B) increased risk associated with the patients gender. C) increased risk of cardiovascular disease as people age. D) elevation of the patients low-density lipoprotein (LDL) level.

D) elevation of the patients low-density lipoprotein (LDL) level. rationale: Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patients LDL level. Decreases in LDL will help reduce the patients risk for developing CAD.

To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review? A. Troponin B. Homocysteine (Hcy) C. Low-density lipoprotein (LDL) D. B-type natriuretic peptide (BNP)

D. B-type natriuretic peptide (BNP) Rationale: Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).

The nurse is caring for a client with a history of atherosclerosis. The client has chest pain that occurs with physical exertion or stress and is relieved with sublingual nitroglycerin. Which disorder should the nurse recognize the client is most likely​ experiencing? A. Prinzmetal angina B. Acute coronary syndrome C. Myocardial infarction D. Stable angina

D. Stable angina Rationale: Stable angina is a predictable form of​ angina, which usually occurs when the work of the heart is increased by physical​ exertion, exposure to​ cold, or stress. Prinzmetal​ (variant) angina occurs unpredictably and often at night. The client is currently experiencing a predictable form of angina. Clinical manifestations of myocardial infarction include pain that is less​ predictable, more​ prolonged, and unrelieved by sublingual nitroglycerin. Clinical manifestations of acute coronary syndrome include pain that is more severe and longer than previously experienced. The pain is not predictable and is unrelieved by sublingual nitroglycerin.

The school nurse is a guest speaker in a high school health class talking about coronary artery disease​ (CAD). Which statement by the nurse is most beneficial to include in the​ presentation? A. "It is much better to learn to prevent​ CAD, rather than to pay for the related treatments and​ surgeries." B. "CAD is the leading cause of death in both men and​ women, which means that all of you are at​ risk." C. ​"If you eat healthy foods you can keep the levels of fat in your bloodstream​ low, which will minimize your risk of​ CAD." D. ​"Some of the things that you can do now to minimize your risk of CAD are avoid fatty​ food, be​ active, and do not​ smoke."

D. ​"Some of the things that you can do now to minimize your risk of CAD are avoid fatty​ food, be​ active, and do not​ smoke." ​Rationale: In this​ case, it is important for the nurse to highlight the changes that are most easily achievable by the high school audience. Although excess lipids in the bloodstream can contribute to the development of​ CAD, it is not enough to say that eating healthy foods will keep lipid levels low.​ Further, high school students are unlikely to be convinced by the cost of CAD care. Telling students that they are all at risk is also unlikely to motivate them to be proactive in avoiding CAD. By warning high school students about their predispositions to the disease and advising them of the modifications they can make to avoid​ it, the audience is much more likely to be receptive to the information.

During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of feeling too tired to get out of bed. Based on these data, the best nursing diagnosis for the patient is: a. activity intolerance related to fatigue. b. disturbed body image related to weight gain. c. impaired skin integrity related to ankle edema. d. impaired gas exchange related to dyspnea on exertion.

a. activity intolerance related to fatigue. Rationale: The patients statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems.

A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurses priority action will be to: a. give IV morphine sulfate 4 mg. b. give IV diazepam (V alium) 2.5 mg. c, increase nitroglycerin (Tridil) infusion by 5 mcg/min. d. increase dopamine (Intropin) infusion by 2 mcg/kg/min.

a. give IV morphine sulfate 4 mg. rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

b. The pain has lasted longer than 30 minutes. Rationale: Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram

c. B-type natriuretic peptide Rationale: B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A twelve-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. Rationale: Lifestyle changes are more likely to be successful when consideration is given to the patients values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low- sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1 to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

c. Serum potassium level 3.0 mEq/L after 1 week of therapy rationale: Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patients heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops: a. ventricular ectopy. b. a dry, hacking cough. c. a systolic BP <90 mm Hg. d. a heart rate <50 beats/minute.

c. a systolic BP <90 mm Hg. Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse knows this finding indicates: a. decreased fluid volume. b. jugular vein atherosclerosis. c. increased right atrial pressure. d. incompetent jugular vein valves.

c. increased right atrial pressure. Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include: a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops. d. skip the digoxin if the pulse is below 60 beats/minute.

c. notify the health care provider if nausea develops. Rationale: Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

A patient who has chronic heart failure tells the nurse, I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating! The nurse will document this assessment finding as: a. orthopnea. b. pulsus alternans. c. paroxysmal nocturnal dyspnea. d. acute bilateral pleural effusion.

c. paroxysmal nocturnal dyspnea. rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the water pill with the heart pill. When planning for the patients discharge the nurse will facilitate a: a. consult with a psychologist. b. transfer to a long-term care facility. c. referral to a home health care agency. d. arrangements for around-the-clock care.

c. referral to a home health care agency. rationale: The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patients home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care.

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that: a. she will take furosemide (Lasix) every day at bedtime. b. the nitroglycerin patch is applied when any chest pain develops. c. she will call the clinic if her weight goes from 124 to 128 pounds in a week. d. an additional pillow can help her sleep if she is feeling short of breath at night.

c. she will call the clinic if her weight goes from 124 to 128 pounds in a week. Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an as needed basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by further elevating the head of the bed.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. Furosemide (Lasix) 60 mg b. Captopril (Capoten) 25 mg c. Digoxin (Lanoxin) 0.125 mg d. Carvedilol (Coreg) 3.125 mg

d. Carvedilol (Coreg) 3.125 mg rationale: Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other medications are appropriate for the patient with ADHF.

Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. I will switch from whole milk to 1% milk. b. I like salmon and I will plan to eat it more often. c. I can have a glass of wine with dinner if I want one. d. I will miss being able to eat peanut butter sandwiches.

d. I will miss being able to eat peanut butter sandwiches. rationale: Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next? a. Document this finding in the patients record. b. Obtain vital signs, including oxygen saturation. c. Have the patient perform the Valsalva maneuver. d. Observe for JVD with the patient upright at 45 degrees.

d. Observe for JVD with the patient upright at 45 degrees. Rationale: When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the JVD in the medical record if it persists when the head is elevated.

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. Weight loss of 2 pounds in 24 hours b. Hourly urine output greater than 60 mL c. Reduction in patient complaints of chest pain d. Reduced dyspnea with the head of bed at 30 degrees

d. Reduced dyspnea with the head of bed at 30 degrees rationale: Because the patients major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patients response.

When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the: a. family history of coronary artery disease. b. increased risk associated with the patients gender. c. increased risk of cardiovascular disease as people age. d. elevation of the patients low-density lipoprotein (LDL) level.

d. elevation of the patients low-density lipoprotein (LDL) level. Rationale: Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patients LDL level. Decreases in LDL will help reduce the patients risk for developing CAD.

When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include: a. canned and frozen fruits. b. fresh or frozen vegetables. c. eggs and other high-protein foods. d. milk, yogurt, and other milk products.

d. milk, yogurt, and other milk products. Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.