ch 37 Care of Patients with Cardiac Problems

17. What is an early sign of left ventricular failure that a patient is most likely to report? a. Nocturia b. Weight gain c. Swollen legs d. Nocturnal coughing

17. dd. Nocturnal coughing

67. A patient is diagnosed with moderate mitral valve stenosis. Which findings is the nurse most likely to encounter during the physical assessment of this patient? (Select all that ap- ply.) a. Dyspnea on exertion b. Orthopnea c. Palpitations d. Asymptomatic e. Neck vein distention

67. a, b, c

68. The nurse hears in report that a patient has been diagnosed with mitral insufficiency. Which early symptom is most likely to be first reported by the patient? a. Atypical chest pain b. Chronic weakness c. Anxiety d. Dyspnea

68. bb. Chronic weakness

A patient is diagnosed with mitral valve steno- sis. Which finding warrants immediate noti- fication of the health care provider because of potential for decompensation? a. Irregularly irregular heart rhythm signifying atrial fibrillation b. Slow, bounding peripheral pulses associ- ated with bradycardia c. An increase and decrease in pulse rate that follows inspiration and expiration d. An increase in pulse rate and blood pres- sure after exertion

69. aa. Irregularly irregular heart rhythm signifying atrial fibrillation

7. Most heart failure begins with failure of the _______________________ and progresses to failure of both ventricle

7. left ventricle

he nurse is assessing the pulses of a patient with valvular disease and finds "bounding" arterial pulses. What is this finding most char- acteristic of? Aortic regurgitation Aortic stenosis Mitral valve prolapse Mitral insufficiency

70. aAortic regurgitation

71. A patient with a history of valvular heart dis- ease requires a routine colonoscopy. The nurse notifies the health care provider to obtain a patient prescription for which type of medica- tion? a. Anticoagulants b. Antihypertensives c. Antibiotics d. Antianginals

71. cc. Antibiotics

72. What is the most common preventable cause of valvular heart disease? a. Congenital disease or malformation b. Calcium deposits and thrombus formation c. Beta-hemolytic streptococcal infection d. Hypertension or Marfan syndrome

72. c c. Beta-hemolytic streptococcal infection

73. The nurse is assessing a patient at risk for val- vular disease and finds pitting edema. This finding is a sign for which type of valvular dis- ease? a. Mitral valve stenosis and insufficiency b. Aortic valve stenosis and insufficiency c. Tricuspid valve prolapse d. Mitral valve prolapse

73. a a. Mitral valve stenosis and insufficiency

74. The health care provider recommends to a patient that diagnostic testing be performed to assess for valvular heart disease. The nurse teaches the patient about which test that is commonly used for this purpose? a. Echocardiography b. Electrocardiography c. Exercise testing d. Thallium scanning

74. a a. Echocardiography

5. Long-term anticoagulant therapy for a patient with valvular heart disease and chronic atrial fibrillation includes which drug? a. Heparin sodium b. Warfarin sodium (Coumadin) c. Diltiazem (Cardizem) d. Enoxaparin (Lovenox)

75. bb. Warfarin sodium (Coumadin)

76. The surgical noninvasive intervention of a bal- loon valvuloplasty is often used for which type of patient? a. Young adults with a genetic valve defect b. Older adults who are nonsurgical candi- dates c. Adults whose open-heart surgery failed d. Older adults who need replacement valves

76. bb. Older adults who are nonsurgical candi- dates

he nurse is caring for a patient who had a valvuloplasty. The nurse monitors for which common complication in the postprocedural period? a. Myocardial infarction b. Angina c. Bleeding and emboli d. Infection

77. cc. Bleeding and emboli

A patient with a prosthetic valve replacement must understand that postoperative care will include lifelong therapy with which type of medication? a. Antibiotics b. Anticoagulants c. Immunosuppressants d. Pain medication

78. bb. Anticoagulants

A patient is a candidate for a xenograft valve. The nurse emphasizes that this type of valve does not require anticoagulant therapy, but will require which intervention? a. Replacement in about 7 to 10 years b. An exercise program to develop collateral circulation c. Daily temperature checks to watch for signs of rejection d. Frequent monitoring for pulmonary ede- ma

79. aa. Replacement in about 7 to 10 years

8. As the ejection fraction decreases, tissue perfu- sion ____________________ and blood accu- mulates in the ___________________ vessels.

8. diminishes; pulmonary

A patient is scheduled for valve surgery. Which medication does the nurse advise the patient to discontinue for several days before the proce- dure? a. Antihypertensives b. Diuretics c. Anticoagulants d. Antibiotics

80. cc. Anticoagulants

What is the most common problem for the pa- tient with valvular heart disease? a. Reduced cardiac output b. Difficulty coping c. Shortness of breath d. Altered body image

81. a Reduced cardiac output

82. The nurse is giving discharge instructions to a patient who had valve surgery. Which home care instructions does the nurse include in the teaching plan? (Select all that apply.) a. Increase consumption of foods high in vi- tamin K. b. Use an electric razor to avoid skin cuts. c. Report any bleeding or excessive bruising. d. Avoid invasive dental procedures unless absolutely necessary e. Watch for and report any fever, drainage, or redness at the site. f. Avoid heavy lifting for 3 to 6 months. g. Report dyspnea, syncope, dizziness, ede- ma, and palpitations. h. Avoid any procedure using magnetic reso- nance if a prosthetic valve was used

82. b, c, e, f, g, h

Vegetation fragments in circulation resulting in a cerebrovascular accident (CVA) or transient isch- emic attack (TIA

83. d d. Systemic emboli

Red, flat pinpoint spots/lesions in mucous mem- brane and conjunctivae

84. c c. Petechiae

Small red streaks or black longitudinal lines of nail bed

85. b b. Splinter hemorrhages

Having a systolic blood pressure higher on expira- tion than on inspiration

86. ee. Pulsus paradoxus

Scratchy, high-pitched sound heard at left lower sternal borde

87. aa. Percardial friction rub

Small nodules on myocardium replaced by scar tis- sue

88. ff. Aschoff bodies

Excess fluid in the pericardial cavity

89. g g. Cardiac tamponade

9. B-type natriuretic peptide (BNP) is produced and released by the ventricles when the patient has _______________________________ as a result of heart failure.

9. fluid overload

Grating pain that is aggravated by breathin

90. b Pericarditis

A new, regurgitant murmur

91. aEndocarditis

Janeway's lesion

92. aEndocarditis

Streptococcal infection

93. c Rheumatic carditis

Osler's node

94. aEndocarditis

Scratchy, high-pitched sound heard on auscultation over left lower sternal borde

95. b Pericarditis

Petechia

96. aEndocarditis

Aschoff 's bodies

97. c Rheumatic carditis

98. Which patients are at greatest risk of develop- ing infective endocarditis? (Select all that ap- ply.) a. IV drug user b. Patient with pancreatitis c. Patient with a myocardial infarction d. Patient with a prosthetic mitral valve re- placement, postoperative e. Patient with mitral stenosis who recently had an abscessed tooth removed f. Older adult patient with urinary tract in- fection and valve damage g. Patient with cardiac dysrhythmias

98. a, d, e, f

9. A patient with aortic valve endocarditis reports fatigue and shortness of breath. Crackles are heard on lung auscultation. What do these as- sessment findings likely indicate? a. Emboli to the lung b. Valve incompetence resulting in heart fail- ure c. Valve stenosis resulting in increased cham- ber size d. Coronary artery disease

99. b. Valve incompetence resulting in heart fail- ure

15. The nurse is assessing a patient with left-sided heart failure. Which assessment findings does the nurse expect to see in this patient? (Select all that apply.) a. Displacement of the apical impulse to the left b. S3 heart sound c. Paroxysmal nocturnal dyspnea d. Jugular venous distention e. Oliguria during the day f. Wheezes or crackles

15. a, b, c, e, f a. Displacement of the apical impulse to the left b. S3 heart sound c. Paroxysmal nocturnal dyspnea e. Oliguria during the day f. Wheezes or crackles

10. Cardiac output (CO) is the product of heart rate (HR) and stroke volume (SV), and an increase in HR results in an immediate _____________________ in cardiac output.

10. increase

100. A patient is admitted for possible infective endocarditis. Which test does the nurse antici- pate will be performed to confirm a positive diagnosis? a. CT scan b. MRI c. Blood cultures d. Echocardiogram

100. cc. Blood cultures

11. The initial compensatory mechanism of the heart that maintains cardiac output is in- creased _______________________________ _______________________.

11. sympathetic stimulation

12. The nurse is taking a history on a patient re- cently diagnosed with heart failure. The patient admits to "sometimes having trouble catching my breath," but is unable to provide more spe- cific details. What question does the nurse ask to gather more data about the patient's symp- toms? a. "Do you have any medical problems, such as high blood pressure?" b. "What did your doctor tell you about your diagnosis?" c. "What was your most strenuous activity in the past week?" d. "How do you feel about being told that you have heart failure?"

12. cc. "What was your most strenuous activity in the past week?"

13. The night shift nurse is listening to report and hears that a patient has paroxysmal nocturnal dyspnea. What does the nurse plan to do next? a. Instruct the patient to sleep in a side-lying position and then check on the patient ev- ery 2 hours to help with switching sides. b. Make the patient comfortable in a bedside recliner with several pillows to keep the patient more upright throughout the night. c. Check on the patient several hours after bedtime and assist the patient to sit up- right and dangle the feet when dyspnea occurs. d. Check the patient frequently because the patient has insomnia due to a fear of suf- focation.

13. c c. Check on the patient several hours after bedtime and assist the patient to sit up- right and dangle the feet when dyspnea occurs.

14. The nurse is assessing a patient with right- sided heart failure. Which assessment findings does the nurse expect to see in this patient? (Select all that apply.) a. Dependent edema b. Weight loss c. Polyuria at night d. Hypotension e. Hepatomegaly f. Angina

14. a, c, e a. Dependent edema c. Polyuria at night e. Hepatomegaly

16. Based on the etiology and the main cause of heart failure, which patient has the greatest need for health promotion measures to prevent heart failure? a. Alzheimer's patient b. Patient with cystitis c. Patient with asthma d. Patient with hypertension

16. dd. Patient with hypertension

18. The nurse is reviewing diagnostic test results for a patient who is hypertensive. Which laboratory result is an early warning sign of decreased heart compliance, and prompts the nurse to immediately notify the health care provider? a. Normal B-type natriuretic peptide b. Decreased hemoglobin and hematocrit c. Elevated thyroxine (T4) d. Presence of microalbuminuria

18. d d. Presence of microalbuminuria

19. The nurse is interviewing a patient with a his- tory of high blood pressure and heart prob- lems. Which statement by the patient causes the nurse to suspect the patient may have heart failure? a. "I noticed a very fine red rash on my chest." b. "I had to take off my wedding ring last week." c. "I've had fever quite frequently." d. "I have pain in my shoulder when I cough."

19. bb. "I had to take off my wedding ring last week."

. A patient who was admitted for newly diag- nosed heart failure is now being discharged. The nurse instructs the patient and family on how to manage heart failure at home. What five major self-management categories should the nurse include?

20. a. Medications b. Activity c. Weight d. Diet e. Symptoms

List one teaching component for each of the self-management categories you identified in the previous questio

21. a. Medications: Take as prescribed; keep pre- scriptions filled; know purpose and side effects for each drug b. Activity: Stay active but avoid overexertion; know your limits; make it a goal to be able to con- verse while exercising c. Weight: Weigh daily at the same time using the same scale and amount of clothing; monitor for fluid reten- tion d. Diet: Limit daily so- dium to 2-3 g; limit daily fluid intake to 2 L e. Symptoms: Notify health care provider im- mediately of any new or worsening symptoms

22. A patient's bilateral radial pulses are occasion- ally weak and irregular. Which assessment technique does the nurse use first to investigate this finding? a. Check the color and the capillary refill in the upper extremities . b. Check the peripheral pulses in the lower extremities. c. Take the apical pulse for 1 minute, noting any irregularity in heart rhythm. d. Check the cardiac monitor for irregularities in rhythm.

22. cc. Take the apical pulse for 1 minute, noting any irregularity in heart rhythm.

23. A patient is at risk for heart failure, but cur- rently has no official medical diagnosis. While assessing the patient's lungs, the nurse hears fine profuse crackles. What does the nurse do next? a. Report the finding to the health care pro- vider. b. Document the finding as a baseline for later comparison. c. Give the patient low-flow supplemental oxygen. d. Ask the patient to cough and reauscultate the lungs.

23. dd. Ask the patient to cough and reauscultate the lungs.

24. A patient is admitted for heart failure and has edema, neck vein distention, and ascites. What is the most reliable way to monitor fluid gain or loss in this patient? a. Check for pitting edema in the dependent body parts. b. Auscultate the lungs for crackles or wheez- ing. c. Assess skin turgor and the condition of mucous membranes. d. Weigh the patient daily at the same time with the same scale.

24. d d. Weigh the patient daily at the same time with the same scale.

25. The home health nurse is evaluating a patient being treated for heart failure. Which state- ment by the patient is the best indicator of hope and well-being as a desired psychological outcome? a. "I'm taking the medication and following the doctor's orders." b. "I'm looking forward to dancing with my wife on our wedding anniversary." c. "I'm planning to go on a long trip; I'll never go back to the hospital again." d. "I want to thank you for all that you have done. I know you did your best."

25. bb. "I'm looking forward to dancing with my wife on our wedding anniversary."

26. The nurse is reviewing the laboratory results for a patient whose chief complaint is dyspnea. Which diagnostic test best differentiates be- tween heart failure and lung dysfunction? Arterial blood gas B-type natriuretic peptide Hemoglobin and hematocrit Serum electrolytes

26. bB-type natriuretic peptide

27. The nursing student is assisting in the care of a patient with advanced right-sided heart failure. In addition to bringing a stethoscope, what ad- ditional piece of equipment does the student bring in order to assess this patient? a. Tape measure b. Glasgow Coma Scale c. Portable Doppler d. Bladder ultrasound scanner

27. aa. Tape measure

28. Which test is the best tool for diagnosing heart failure? a. Echocardiography b. Pulmonary artery catheter c. Radionuclide studies d. Multigated angiographic (MUGA) scan

28. aa. Echocardiography

40. A patient has recently been diagnosed with acute heart failure. Which medication order does the nurse question? a. Dobutamine (Dobutrex), a beta-adrenergic agonist b. Milrinone (Primacor), a phosphodiester- ase inhibitor c. Levosimendan (Simdax), a positive inotro- pic d. Carvedilol (Coreg), a beta blocker

40. d d. Carvedilol (Coreg), a beta blocker

29. A patient with heart failure has inadequate tis- sue perfusion. Which nursing interventions are included in the plan of care for this patient? (Select all that apply.) a. Monitor respiratory rate, rhythm, and quality every 1 to 4 hours. b. Auscultate breath sounds every 4 to 8 hours. c. Provide supplemental oxygen to maintain oxygen saturation at 90% or greater. d. Place the patient in a supine position with pillows under each leg. e. Assist the patient in performing cough- ing and deep-breathing exercises every 2 hours.

29. a, b, c, e

30. Which interventions are effective for a patient with a potential for pulmonary edema caused by heart failure? (Select all that apply.) a. Sodium and fluid restriction b. Slow infusion of hypotonic saline c. Administration of potassium d. Administration of loop diuretics e. Position in semi-Fowler's to high-Fowler's position f. Weekly weight monitoring

30. a, d, e

36. A patient is receiving digoxin therapy for heart failure. What assessment does the nurse per- form before administering the medication? a. Auscultate the apical pulse rate and heart rhythm. b. Assess for nausea and abdominal disten- tion. c. Auscultate the lungs for crackles. d. Check for increased urine output.

36. aa. Auscultate the apical pulse rate and heart rhythm.

38. Which laboratory test monitors for potential cardiac problems and digoxin toxicity? a. Complete blood count b. BUN and creatinine level c. Serum potassium level d. Prothrombin time and INR

38. c c. Serum potassium level

39. A patient is receiving an infusion of nesiritide (Natrecor) for treatment of heart failure. What is the priority nursing assessment while ad- ministering this medication? a. Monitor for hypotension. b. Assess for cardiac dysrhythmias. c. Observe for respiratory depression. d. Monitor for peripheral vasoconstriction.

39. aa. Monitor for hypotension.

41. A patient has an ejection fraction of less than 30%. The nurse prepares to provide patient education about which potential treatment? a. Automatic implantable cardio-defibrillator b. Heart transplant c. Mechanical implanted pump d. Ventricular reconstructive procedures

41. a a. Automatic implantable cardio-defibrillator

42. The nurse identifies a priority problem of fa- tigue and weakness for the patient with heart failure. After ambulating 200 feet down the hall, the patient's blood pressure change is more than 20 mm Hg. How does the nurse interpret this data? a. The patient is building endurance . b. The activity is too stressful. c. The patient could walk farther. d. The activity is appropriate.

42. b. b. The activity is too stressful.

43. A patient with heart failure is anxious to recov- er quickly. After ambulating with the UAP, the nurse observes that the patient has dyspnea. The nurse asks the patient to rate her exertion on a scale of 1 to 20 and the patient says, "I can keep going. It's only about a 15." What is the nurse's best response? a. "Slow down a bit; ideally you should be less than 12." b. "As long as you are less than 18, you can keep going." c. "Stop right now; you should not tax your heart beyond 5." d. "You should go slower; you cannot reach level 0 in one day."

43. aa. "Slow down a bit; ideally you should be less than 12."

44. Why does the nurse document the precise lo- cation of crackles auscultated in the lungs of a patient with heart failure? a. Crackles will eventually change to wheezes as the pulmonary edema worsens. b. The level of the fluid spreads laterally as the pulmonary edema worsens. c. The level of the fluid ascends as the pulmo- nary edema worsens. d. Crackles will eventually diminish as the pul- monary edema worsens.

44. cc. The level of the fluid ascends as the pulmo- nary edema worsens.

45. A patient comes to the ED extremely anxious, tachycardiac, and struggling for air with a moist cough productive of frothy, blood-tinged sputum. What is the priority nursing interven- tion? a. Apply a pulse oximeter and cardiac moni- tor. b. Administer high-flow oxygen therapy via facemask. c. Prepare for continuous positive airway pressure ventilation. d. Prepare for intubation and mechanical ventilation.

45. b. Administer high-flow oxygen therapy via facemask.

46. A patient is treated for acute pulmonary ede- ma. Which medications does the nurse prepare to administer to this patient? (Select all that apply.) a. Sublingual nitroglycerin b. IV Lasix c. IV morphine sulfate d. IV beta blocker e. IV nitroglycerin

46. a, b, c, e

47. What is the expected outcome for the collabor- ative problem potential for pulmonary edema? a. No dysrhythmias b. Clear lung sounds c. Less fatigue d. No disorientation

47. b b. Clear lung sounds

The nurse is teaching a patient with heart fail- ure about signs and symptoms that suggest a return or worsening of heart failure. What does the nurse include in the teaching? (Select all that apply.) a. Rapid weight loss of 3 lbs in a week b. Increase in exercise tolerance lasting 2 to 3 days c. Cold symptoms (cough) lasting more than 3 to 5 days d. Excessive awakening at night to urinate e. Development of dyspnea or angina at rest or worsening angina f. Increased swelling in the feet, ankles, or hands

48. c, d, e, f

A patient is prescribed bumetanide (Bumex). What is an important teaching point for the nurse to include about this medication? a. Caution to move slowly when changing positions, especially from lying to sitting b. Information about potassium-rich foods to include in the diet c. Written instructions on how to count the radial pulse rate d. Information about low-sodium diets and reading food labels for sodium content

49. bb. Information about potassium-rich foods to include in the diet

he nurse is teaching a patient about the treat- ment regimen for heart failure. Which state- ment by the patient indicates a need for further instruction? a. "I must weigh myself once a month and watch for fluid retention." b. "If my heart feels like it is racing, I should call the doctor." c. "I'll need to consider my activities for the day and rest as needed." d. "I'll need periods of rest and activity, and I should avoid activity after meals."

50. a a. "I must weigh myself once a month and watch for fluid retention."

Usually coexists with some degree of mitral stenosi

51. b b. Mitral valve insufficiency

Classic signs of dyspnea, angina, and syn- cope

52. d d. Aortic stenosis

Hepatomegaly is a late sig

53. aa. Mitral valve stenosis

A high-pitched, blowing decrescendo dia- stolic murmu

54. e e. Aortic insufficiency

Irregular rhythm; atrial fibrillation can cause embol

55. a, ba. Mitral valve stenosis b. Mitral valve insufficiency

Most patients are asymptomati

56. c c. Mitral valve prolaps

Right-side heart failure; later cardiac output fail

57. aa. Mitral valve stenosis

The patient may experience palpitations while lying on left side

58. e e. Aortic insufficiency

Symptom-free for decades, later related to left ventricle failure

59. bb. Mitral valve insufficiency

Increased volume and pressure de- velop and result in peripheral edema

6. aa. Right-sided heart (ventricular) failure

Rumbling apical diastolic murmur

60. aa. Mitral valve stenosis

Right-sided failure results in neck vein dis- tentio

61. a, ba. Mitral valve stenosis b. Mitral valve insufficiency

Leaflets enlarge and fall back into left atrium during systol

62. c c. Mitral valve prolaps

Normal heart rate and blood pressure

63. c c. Mitral valve prolaps

Becoming a disorder of aging populations

64. d d. Aortic stenosis

Murmur, systolic crescendo-decrescendo

65. d d. Aortic stenosis

S3 often present due to severe regurgitation

66. bb. Mitral valve insufficiency

31. An older adult patient with heart failure is vol- ume depleted and has a low sodium level. The health care provider has ordered valsartan (Di- ovan), an angiotensin-receptor blocker (ARB). After the initial dose, what does the nurse care- fully monitor this patient for? a. Hypotension b. Cough c. Fluid retention d. Chest pain

aa. Hypotension

Can occur when cardiac output re- mains normal or above normal

cc. High-output failure

34. A patient is prescribed diuretics for treatment of heart failure. Because of this therapy, the nurse pays particular attention to which labo- ratory test level? Peak and trough of medication Serum potassium Serum sodium PT and PTT

bSerum potassium

Decreased tissue perfusion from poor cardiac output and pulmonary conges- tion from increased pressure in the pulmonary vessels

bb. Left-sided heart (ventricular) failure

5. An older adult patient is taking digoxin for treatment of heart failure. What is the priority nursing action for this patient related to the medication therapy? a. Give the medication in conjunction with an antacid. b. Keep the patient on the cardiac monitor and observe for ventricular dysrhythmias. c. Check that the dose is in the lowest pos- sible range for therapeutic effect. d. Advise the patient that there is increased mortality related to toxicity.

cc. Check that the dose is in the lowest pos- sible range for therapeutic effect.

33. A patient with heart failure has excessive aldo- sterone secretion and is therefore experiencing thirst and continuously asking for water. What does the nurse instruct the unlicensed assistive personnel (UAP) to do? a. Severely restrict fluid to 500 mL plus out- put from the previous 24 hours. b. Give the patient as much water as desired to prevent dehydration. c. Restrict fluid to a normal 2 L daily, with accurate intake and output. d. Frequently offer the patient ice chips and moistened toothettes

cc. Restrict fluid to a normal 2 L daily, with accurate intake and output.

32. The health care provider has ordered an ARB for a patient with heart failure. The parameters are to maintain a systolic blood pressure rang- ing from 90 to 110 mm Hg. Today the patient has a blood pressure of 110/80 mm Hg, but shows acute confusion. What is the nurse's pri- ority action? a. Give the medication because blood pres- sure is within the parameters. b. Call the health care provider about the new onset of confusion. c. Hold the medication and document the new findings. d. Assess the patient for other symptoms of decreased tissue perfusion.

dd. Assess the patient for other symptoms of decreased tissue perfusion.

Percentage of blood ejected from the heart during systole

dd. Ejection fraction

37. The nurse is reviewing the ECG of a patient on digoxin therapy. What early sign of digitalis toxicity does the nurse look for? a. Tachycardia b. Peaked T wave c. Atrial fibrillation d. Loss of P wave

dd. Loss of P wave

Alternate in strength

e e. Pulsus alternans

Activated by reduced blood flow to the kidneys

ff. Renin-angiotensin system (RAS)