🖤 fail
The nurse is caring for a client with worsening congestive heart failure. Which of the following are expected findings in a client with this condition? Select all that apply.
-Shortness of breath at rest Because of the loss of effective pumping, the heart is unable to meet oxygen demands, even at rest. The client with worsening congestive heart failure will have shortness of breath at rest, and profound shortness of breath with normal activities such as walking. -Tachycardia The client with worsening heart failure will have tachycardia as the heart makes an attempt to keep up with cardiovascular demands. -Slow capillary refill Circulation is compromised in the client with congestive heart failure, so capillary refill time is slowed.
The nurse is caring for a client with heart failure who is receiving home health care. Upon reviewing the client data over the last three days (shown in the graphic), what priority follow up question should the nurse ask?
Annswerr- are you having any shortness of breath? The client has gained 7 pounds in two days. This, along with the increase in blood pressure, demonstrates that the client is experiencing signs of volume overload. The nurse should ask about shortness of breath to determine if the client is having other complications associated with fluid overload, such as pulmonary edema. Have you been eating poorly? A weight gain of 7 lbs in two days is unlikely to be related to nutritional intake, especially considering the client's history of heart failure. Have you taken your blood pressure medication? It is not a priority over assessing respiratory status. It is possible that the client didn't take their medication, thus causing this volume overload and exacerbation. However, it is more important to determine whether the client is suffering from pulmonary edema first. Also, this question can be perceived poorly by the client as accusatory. When did you last calibrate your scales? It assumes the weight measurements must be wrong. It also is not a priority over evaluating the client's respiratory status
A client with heart disease has developed pulmonary edema and is having difficulties breathing. The nurse notes that the client is breathing at a rate of 28/min and has an oxygen saturation of 90% on room air. Which best describes the first response of the nurse?
Answer - Administer oxygen through a face mask to correct saturation levels Pulmonary edema develops as increased congestion in the pulmonary system, making breathing difficult for the affected client. In this situation, the client is symptomatic and is struggling with decreased oxygen levels, which can lead to hypoxia. The first action of the nurse is to administer oxygen to correct oxygen saturation levels. Prepare the client for a thoracentesis Fluid does not accumulate in the thoracic space from pulmonary edema. Rather, fluid accumulates in the lung tissue, making it difficult for gas exchange. Gather supplies to assist with intubation Intubation is not necessary if the client has an oxygen saturation of 90%. Administer pain medication to slow the client's breathing Pain medication should not be given to slow breathing. The client is breathing at a rapid rate because of impaired gas exchange. This rate is necessary to keep the client's oxygen level up.
The nurse is caring for a client who is suffering from heart failure. The client has been experiencing weight gain and peripheral edema. Which of the following interventions should the nurse employ?
Answer -Auscultate breath sounds at least every 2 hours Fluid volume excess develops when the client has excess circulating volume in the bloodstream or the body is retaining enough fluid to cause fluid to move to the tissues outside of circulation. It may be manifested by such signs or symptoms as swelling, wet breath sounds, and weight gain. Nursing interventions include reducing edema, checking breath sounds regularly for changes, and monitoring intake and output at least every 4 hours. Placing the legs in the dependent position would allow for further fluid accumulation in the extremities. Monitor the client's intake and output every 24 hours Intake and output should be monitored every 4 hours. Keep the client's legs in the dependent position If a client is experiencing dependent edema due to heart failure, it is therapeutic to keep the extremities elevated to reduce the edema. Place the client on a low-magnesium diet A client with fluid retention due to heart failure should be placed on a low-sodium diet, because sodium retains water and the client needs to get rid of water.
The nurse is caring for a client with heart failure. The nurse knows that the client is experiencing right-sided heart failure based on which assessment?
Answer- Pitting edema in the bilateral legs In right-sided heart failure, fluid backs up to the body, not the lungs. This causes edema in the lower extremities. Course crackles in the lungs This indicates left-sided heart failure, because in this condition fluid backs up to the lungs and causes the auditory sounds over the lung fields to be crackles. Shortness of breath upon exertion This indicates left-sided heart failure. Fixed pupils This indicates a neurological deficit, not heart failure.
A 66-year-old client has been in the hospital for care and management of heart failure. There are orders for discharge and the nurse is reviewing discharge instructions with the client. Which of the following information would be included as part of discharge information for this client?
Answer- The client should not eat more than 2,000 mg of sodium each day Excess sodium intake can cause changes in circulatory volume, potentially increasing fluid and contributing to buildup. Many clients with heart failure are restricted in their dietary sodium to 2,000 mg a day, although in some cases, the provider may allow for more or less, depending on the client's condition. The client should not have more than 3 alcoholic beverages per day While a client with heart failure may drink alcohol, it must be done in moderation. Three alcoholic beverages per day is too much alcohol, and would be considered moderate to heavy drinking. A client with heart failure should be counseled not to drink more than one alcoholic beverage in a day, and to avoid drinking alcohol every day. The client should take non-steroidal anti-inflammatory drugs (NSAIDs) for pain control and not acetaminophen NSAIDS may worsen heart failure and should be avoided. The client should restrict fluid intake to less than 4,000 mL per day Heart failure can cause an increase in fluid in the circulatory system. Most heart failure clients are instructed to restrict fluid to 1,000 to 2,000 mL per day.
A nurse is caring for a client with heart failure. During the shift assessment the nurse notes that the client has pitting edema, shortness of breath, and which heart sound?
Answer-Gallop If a gallop sound (S3) is heard, this indicates blood prematurely rushing into the ventricle. This is often related to volume overload as seen in heart failure, but could also be caused by pulmonary hypertension or coronary artery disease. Swooshing Swooshing sounds indicate murmurs, which are evidence of valvular disease (stenosis or regurgitation). Clicking Clicks are often heard with mitral valve prolapse or aortic stenosis, or can be heard in someone with a prosthetic valve. Rubbing Rubbing indicates the presence of inflammation in the pericardium, such as in pericarditis.
A nurse is performing an assessment on a client with heart failure. The nurse checks the client's peripheral pulses in the feet and documents the pulses as 1+. Which best describes this type of pulse? 1)Weak and barely palpable 2)Absent 3)Bounding and strong 4)Normal and easily palpable
Answer-Weak and barely palpable During the nursing head-to-toe assessment, peripheral pulses can be checked and then graded according to their intensity. A nurse who feels a peripheral pulse as described as a 1+ would most likely feel a weak and thready, or barely palpable pulse. Absent A 0 indicates an absent pulse. Bounding and strong A 3+ indicates a bounding pulse. Normal and easily palpable A 2+ indicates a normal pulse.
The nurse is caring for a client who has +3 pitting edema in the legs and a potassium level of 2.3 mEq/L. The nurse expects which of the following diuretics to be ordered? 1) Spironolactone (Aldactone) 2)Furosemide (Lasix) 3)Bumetamide (Bumex) 4)Ethacrynic Acid (Edecrin)
Right answer - Spironolactone (Aldactone) This client has a low potassium level, and the nurse knows that many diuretics are potassium-wasting diuretics, which would be contraindicated for this client. Spironolactone is the only potassium sparing diuretic out of the answer options. Other rationale- Furosemide is a loop diuretic, which causes potassium to be excreted out of the body. Bumetamide is a loop diuretic, which causes potassium to be excreted out of the body. Ethacrynic Acid is also a loop diuretic, which causes potassium to be excreted out of the body.
A nurse is caring for a client with left-sided heart failure. Which of the following findings would the nurse expect while assessing this client?
Right answer- Crackles in the lungs In left-sided heart failure, the effects are seen in the lungs. The nurse will hear crackles in the lungs caused by fluid overload. Dry, hacking cough This client would have a wet-sounding cough, not a dry cough. Flattened jugular veins Flattened jugular veins are not an indication of left-sided heart failure. Pitting edema in bilateral lower extremities This finding would indicate right-sided heart failure, because the blood backs up to the rest of the body, not the lungs.
