Chapter 26 Nursing Assessment and Care of Patients with Heart Failure
The nurse is obtaining data to assess a client for fluid retention. Which questions should the nurse include in the assessment? Select all that apply.
"Are your shoes tight?" "Have you had any weight gain recently?"
The nurse is taking a health history of a client with suspected heart failure. Which question assesses respiratory function?
"How many flights of stairs can you climb without dyspnea?"
he nurse is providing teaching to a client undergoing a heart transplant. Which statement made by the client indicates the need for further teaching?
"I am only at risk for rejection right after surgery."
Which statement made by a client indicates a possible exacerbation of heart failure (HF)?
"I have gained 8 pounds this week."
In heart failure, which part of the heart fails first?
Left ventricle- fails first because the left ventricle has the greatest workload.
The nurse is caring for a client who develops pulmonary edema. Which classic symptom can the nurse expect to find?
Pink, frothy sputum
Which of the following is the most common cause of right-sided heart failure?
Left-sided heart failure
The nurse is caring for a client with heart failure who has a pattern of shallow respirations building to deep breaths, followed by apnea. Which of the following does this describe?
Cheyne-Stokes breathing
The nurse is caring for a client about to undergo cardiac catheterization. Which of the following statements made by the client indicate an understanding of the procedure? Select all that apply.
"I need to inform the health-care provider that I am allergic to contrast dye." "It may feel warm when they inject the dye." "They will check my vital signs and electrocardiogram (ECG) during the procedure."
The nurse is teaching a client with heart failure about nutrition. Which statement made by the client indicates an understanding of the teaching?
"I need to reduce the amount of fluids I drink like the health-care provider said."
The nurse is teaching a client with heart failure about ways to prevent orthopnea. Which statement made by the client indicates an understanding of the teaching?
"I should sleep with two or three pillows so I can breathe easier."
The nurse is providing teaching to a client taking bumetanide (Bumex). Which statement made by the client indicates an understanding of the teaching?
"I should take this medication early so I don't pee all night."
The nurse is providing teaching for a client taking metoprolol succinate (Toprol XL). Which statement made by the client indicates a need for further teaching?
"If my systolic blood pressure (BP) is less than 100 mm Hg, I can take the pill."-client should notify the HCP.
A client asks the nurse about the goal for heart failure treatment. Which response by the nurse is best?
"The goal is to improve your heart's ability to pump and decrease oxygen demands of the heart."
The nurse is caring for a group of clients. Which client should the nurse identify as high risk for heart failure?
A client with hypertension
The nurse is caring for a group of clients with heart failure (HF). Which client should the nurse see first?
A client with new-onset confusion
The nurse is caring for a group of clients. Which client will warrant a call to the health-care provider?
A client with pink, frothy sputum
Which new class of medications used to treat heart failure (HF) has reduced hospitalizations and deaths from chronic HF?
Angiotensin receptor neprilysin inhibitors (ARNIs)-
A client with heart failure is taking furosemide (Lasix). The nurse is teaching about appropriate food choices when taking furosemide. Which food selection by the client indicates understanding of this teaching?
Baked potato
The nurse is reviewing laboratory results before administering medication and notes a potassium level of 2.5. Which medication would the nurse question?
Bumetanide (Bumex)-potassium wasting-
The nurse is assessing a client with heart failure. What should the nurse expect to hear upon auscultating lung sounds?
Crackles
The nurse is caring for a client with left-sided heart failure. Which clinical manifestations should the nurse expect to see? Select all that apply.
Crackles Dry, hacking cough Orthopnea Cyanosis Paroxysmal nocturnal dyspnea
The nurse is teaching a client about monitoring fluid status at home. How often should the nurse encourage the client to weigh?
Daily
The nurse is reviewing laboratory values for a client with heart failure. Which of the following should the nurse expect to find?
Elevated brain natriuretic peptide (BNP)
The nurse is caring for a client with heart failure (HF). Which medication does the nurse know is often a first-choice drug for HF?
Enalapril (Vasotec)- (ACE) inhibitors are the first drug of choice to treat heart failure.
Which of the following are clinical manifestations related to a decrease in oxygenation? Select all that apply.
Fatigue Dyspnea Confusion Cyanosis Insomnia
Which of the following are the earliest symptoms of chronic heart failure? Select all that apply.
Fatigue Weakness
Which of the following is the most common cause of left-sided heart failure?
Hypertension- number-one cause of left-sided heart failure.
The nurse notes a client's chest tube drainage is 200 mL/hr. For which of the following should the nurse monitor the client?
Hypovolemia
The nurse is preparing to administer digoxin (Lanoxin). Which of the following interventions should the nurse implement?
Monitor apical heart rate for 1 minute.
The nurse is preparing to administer cyclosporine (Neoral) 15 mg/kg/day in two divided doses to a client who weighs 105 kg. How many milligrams will the nurse administer per dose? Enter the numeral only.
Multiply 15 by 105 = 1575 and divide by 2 = 787.5 per dose
The nurse is caring for a client who reports pink and frothy sputum. Which action should the nurse take first?
Notify the health-care provider (HCP) immediately.-Pulmonary edema is life threatening and should be reported immediately.
The nurse is reviewing laboratory results of a client who is taking spironolactone (Aldactone) and notes a potassium level of 6.5. Which action should the nurse take?
Notify the health-care provider (HCP).
The nurse is caring for a client with heart failure who awakens during the night with feelings of suffocation and anxiety. The nurse knows the client is experiencing which of the following?
Paroxysmal nocturnal dyspnea
The nurse is administering furosemide (Lasix) to a client with heart failure. Which laboratory value would concern the nurse?
Potassium 2.8 mEq/dL (3.5 to 5.5 mEq/dL.)
The nurse is providing teaching for a client who is being sent home with a Holter monitor. Which information is important for the nurse to include in the teaching?
Press the button on the monitor if symptoms occur.
Clients with heart failure typically present with a decrease of which of the following?
Red blood cells (RBCs)- due to hemodilution from fluid overload and decreased angiotensin-converting enzyme (ACE) action
The nurse is preparing to draw blood for a creatine kinase (CK) test. Which of the following should the nurse avoid before drawing the blood?
Starting the client's intravenous (IV) line -A CK can show a false elevation from cell trauma during certain procedures.
Which of the following describes Stage C heart failure (HF)?
Those with heart failure with reduced ejection fraction and symptoms
The nurse is caring for a client with heart failure. Which intervention should the nurse implement?
Weigh the client daily at the same time.
The nurse is caring for a client with right-sided heart failure. Which clinical manifestations can the nurse expect to find? Select all that apply
Weight gain Dependent peripheral edema Hepatomegaly Ascites
The nurse is caring for a client who underwent a heart transplant. Which of the following would be of most concern to the nurse?
Yellow-green sputum