Course Point-Cardiac
During a head-to-toe assessment of a client with congestive heart failure, what should the nurse checks for? .
-dyspnea -auscultate apical heart rate and count radial heart rate -measure BP -document any sign of peripheral edema, lethargy, or confusion.
A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?
Blood pressure 80/46 mm Hg
Which is a key diagnostic indicator of heart failure?
Brain natriuretic peptide (BNP)
A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?
Class I (Mild)
What decreases contractility of the heart?
Digoxin SNS Catecholamines
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?
Dizziness
The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?
Echocardiogram
What is commonly the earliest symptom of chronic heart failure? And what is it caused by?
Fatigue caused by decreased cardiac output and tissue oxygenation.
A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload?
Head of the bed elevated 45 degrees and lower arms supported by pillows
A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?
Hold the medication and call the health care provider.
What kind of medication is digoxin?
Inotropic medication
A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? a. JVD is noted at the level of the sternal angle. b. No JVD is present. c. JVD is noted 4 cm above the sternal angle. d. JVD is noted 2 cm above the sternal angle.
JVD is noted 4 cm above the sternal angle.
Are Hypotension and tachycardia a late or early sign of decompensating heart failure?
LATE
Are Pedal edema and nocturia early or late symptoms of heart failure?
Late s/s
The client with cardiac failure is taught to report which symptom to the health care provider or clinic immediately? a. Weight loss b. Ability to sleep through the night c. Increased appetite d. Persistent cough
Persistent cough
Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?
Preload
A client has been diagnosed with heart failure. What is the major nursing outcome for the client?
Reduce the workload on the heart.
A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure?
Right-sided heart failure
Which is a potassium-sparing diuretic used in the treatment of heart failure?
Spironolactone
A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. Which finding indicates a need for immediate attention?
The Lung Congestion
A client taking an ACE inhibitor has developed a dry, hacking cough. Because of this side effect, the client no longer wants to take that medication. What medication that has similar hemodynamic effects does the nurse anticipate the health care provider ordering? a. Valsartan b. Isosorbide dinitrate c. Metoprolol d. Furosemide
Valsartan
What are the signs and symptoms included with Right Ventricular Failure include:
Weakness; Ascites; Weight gain; Nausea, vomiting; Dysrhythmias; Elevated central venous pressure; Jugular vein distention.
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound?
a third heart sound (S3).
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? a. Dyspnea on exertion b. Tachycardia c. Decreased urinary output d. Hypotension
a. Dyspnea on exertion
A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply. a. Examine the client's eyes for excess tears. b. Monitor the client for signs of lethargy or confusion. c. Examine the client's joints for crepitus. d. Examine the client's neck for distended veins.
a. Examine the client's eyes for excess tears. b. Monitor the client for signs of lethargy or confusion.
A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply. a. Examine the client's neck for distended veins. b. Examine the client's joints for crepitus. c. Examine the client's eyes for excess tears. d. Monitor the client for signs of lethargy or confusion.
a. Examine the client's neck for distended veins. d. Monitor the client for signs of lethargy or confusion
A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply. a. Monitor the client for signs of lethargy or confusion. b. Examine the client's joints for crepitus. c. Examine the client's neck for distended veins. d. Examine the client's eyes for excess tears.
a. Monitor the client for signs of lethargy or confusion. c. Examine the client's neck for distended veins.
The nurse is working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for the nurse to closely monitor an older adult receiving digitalis preparations for cardiac disorders? a. Older adults are at increased risk for toxicity. b. Older adults are at increased risk for cardiac arrests. c. Older adults are at increased risk for hyperthyroidism. d. Older adults are at increased risk for asthma.
a. Older adults are at increased risk for toxicity.
A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess? a. diuretics. b. antiembolism stockings. c. anticoagulants. d. oxygen.
a. diuretics.
The nurse is interviewing a client during an initial visit at a cardiologist's office. What symptom will the nurse expect to find as an early symptom of chronic heart failure? a. fatigue b. nocturia c. irregular pulse d. pedal edema
a. fatigue
A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber? a. heart rate of 55 beats per minute b. blood pressure of 125/80 c. atrial fibrillation rhythm d. urine output of 300 mL in eight hours
a. heart rate of 55 beats per minute
A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber? a. heart rate of 55 beats per minute b. blood pressure of 125/80 c. urine output of 300 mL in eight hours d. atrial fibrillation rhythm
a. heart rate of 55 beats per minute
A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective? a. peripheral edema b. bradycardia c. skin rash d. postural hypotension
a. peripheral edema
A nurse is caring for a client with a cardiac disorder who is prescribed diuretics. What important factor should the nurse include in this client's teaching plan? a. A discussion of the required room temperature conditions in the home environment. b. A discussion of the signs and symptoms of electrolyte and water loss. c. A discussion of the signs and symptoms of anemia. d. A discussion on how to avoid direct sunlight when outdoors.
b. A discussion of the signs and symptoms of electrolyte and water loss.
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? a. Nocturia b. Dizziness c. Tachycardia d. Ascites
b. Dizziness
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? a. Assessing the client's vital signs every 4 hours b. Weighing the client daily at the same time each day c. Measuring and recording fluid intake and output d. Checking the client's lungs for crackles during every shift
b. Weighing the client daily at the same time each day
A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of a. myocardial infarction. b. pulmonary embolism. c. pneumonia. d. pulmonary edema.
b. pulmonary embolism.
A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion? a. Assess for elevated blood potassium levels. b. Assess for reduced blood sodium levels. c. Assess for elevated blood urea nitrogen levels. d. Assess for reduced urine output.
c. Assess for elevated blood urea nitrogen levels.
A client has been diagnosed with heart failure. What is the major nursing outcome for the client? a. Walk 30 minutes three times a week. b. Maintain a healthy diet. c. Reduce the workload on the heart. d. Sleep 8 hours per night.
c. Reduce the workload on the heart.
Which is a potassium-sparing diuretic used in the treatment of heart failure? a. Chlorothiazide b. Bumetanide c. Spironolactone d. Ethacrynic acid
c. Spironolactone
The nurse is administering furosemide to a client with heart failure. What best describes the therapeutic action of the medication? a. Furosemide promotes sodium secretion into the distal tubule. b. Furosemide blocks reabsorption of potassium on the collecting tubule. c. The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels. d. The medication promotes potassium secretion into the distal tubule and constrict renal vessels.
c. The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels.
Frequently, what is the earliest symptom of left-sided heart failure? a. anxiety b. chest pain c. dyspnea on exertion d. confusion
c. dyspnea on exertion
The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival? a. cholestyramine b. diltiazem c. lisinopril d. bumetanide
c. lisinopril
The nurse is assigned to care for a patient with heart failure. What classification of medication does the nurse anticipate administering that will improve symptoms as well as increase survival? a. Bile acid sequestrants b. Diuretic c. Calcium channel blocker d. ACE inhibitor
d. ACE inhibitor
A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion? a. Assess for elevated blood potassium levels. b. Assess for reduced blood sodium levels. c. Assess for reduced urine output. d. Assess for elevated blood urea nitrogen levels.
d. Assess for elevated blood urea nitrogen levels.
Which assessment parameter is important for the client diagnosed with congestive heart failure? a. Photosensitivity b Excess tears c. Crepitus d. Distended Veins
d. Distended Veins
The nurse is performing an initial assessment of a client diagnosed with heart failure. The nurse also assesses the client's sensorium and LOC. Why is the assessment of the client's sensorium and LOC important in clients with heart failure? a. Decreased LOC causes an exacerbation of the signs and symptoms of heart failure. b. Clients with heart failure are susceptible to overstimulation of the sympathetic nervous system. c. The most significant adverse effect of medications used for heart failure treatment is altered LOC. d. Heart failure ultimately affects oxygen transportation to the brain.
d. Heart failure ultimately affects oxygen transportation to the brain.
A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure? a. Hypertension causes the heart's chambers to enlarge and weaken. b. Heart failure occurs when blood pressures drops. c. Hypertension in older males regularly leads to heart failure. d. Hypertension causes the heart's chambers to shrink.
d. Hypertension causes the heart's chambers to shrink. (making it impossible for the ventricles to eject all the blood they receive.)
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client? a. Nausea b. Jugular venous distention c. Pedal edema d. Pulmonary congestion
d. Pulmonary congestion
A client with a history of heart failure is returning from the operating room after inguinal hernia repair and the nurse assesses a low pulse oximetry reading. What is the most important nursing intervention? a. Assess for jugular vein distention. b. Administer pain medication. c. Assess the surgical incisional area. d. Titrate oxygen therapy.
d. Titrate oxygen therapy.
The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer? a. Carvedilol (Coreg) b. Metolazone (Zaroxolyn) c. Digoxin (Lanoxin) d. Valsartan (Diovan)
d. Valsartan (Diovan)
A client taking an ACE inhibitor has developed a dry, hacking cough. Because of this side effect, the client no longer wants to take that medication. What medication that has similar hemodynamic effects does the nurse anticipate the health care provider ordering? a. Metoprolol b. Furosemide c. Isosorbide dinitrate d. Valsartan
d. Valsartan (angiontensin II)
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? a. Assessing the client's vital signs every 4 hours b. Checking the client's lungs for crackles during every shift c. Measuring and recording fluid intake and output d. Weighing the client daily at the same time each day
d. Weighing the client daily at the same time each day
A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess? a. oxygen b. anticoagulants. c. antiembolism stockings. d. diuretics.
d. diuretics.
A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)?
decrease in renal perfusion
The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema?
decreased left ventricular pumping
The main types of catecholamines?
dopamine, norepinephrine, and epinephrine. Epinephrine is also known as adrenaline
Frequently, what is the earliest symptom of left-sided heart failure?
dyspnea on exertion
The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart?
echocardiogram
Peripheral edema is a sign of?
fluid volume excess and worsening heart failure
The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure?
furosemide
The nurse is assessing a newly admitted client with chest pain. What medical disorder is most likely causing the client to have jugular vein distention? a. myocardial infarction (MI) b. abdominal aortic aneurysm c. pneumothorax d. heart failure
heart failure
The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed? a. implantable cardiac defibrillator (ICD) b. cardiac resynchronization therapy c. ventricular access device d. heart transplant
heart transplant
A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment?
moist, gurgling respirations
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?
nausea and vomiting
When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating
orthopnea.
What are adverse reactions to captopril?
skin rash and postural hypotension
An individual with worsening heart failure who i not responding to captopril, will most like experience tachycardia or bradycardia?
tachycardia
The nurse is preparing to administer hydralazine and isosorbide dinitrate. When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse?
visual disturbances