Honan, Chapter 15: Nursing Management: Patients With Complications From Heart Disease
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?
"I sleep on three pillows each night."
A nurse is performing chest compressions on a 60-year-old client in cardiac arrest. To which depth would the nurse compress the chest?
2 inches (5 cm)
A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be?
30%
All of the following are clinical signs and symptoms of left-sided heart failure except for:
A central venous pressure reading greater than 8 mm Hg.
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?
ACE inhibitor
A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The clients reports that these symptoms came on suddenly. The nurse knows that these are symptoms of what condition?
Acute pulmonary edema
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
BP and pulse measurements every 15 to 30 minutes
A patient has been admitted to the hospital with exacerbation of heart failure (HF) that has resulted in pulmonary and peripheral edema. The nurse has been carefully monitoring the trajectory of the patient's signs and symptoms of HF. How can the nurse best monitor the patient's fluid balance?
By performing daily weights at the same time each day
A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved?
Decrease in central venous pressure (CVP)
A client is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client?
Digoxin immune FAB
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
Dyspnea on exertion
The diagnosis of heart failure is usually confirmed by which of the following?
Echocardiogram
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
Echocardiogram
A 69-year-old man has been experiencing progressive dyspnea and activity intolerance in recent months and is currently undergoing a diagnostic workup for heart failure (HF). During echocardiography, systolic HF could be differentiated from diastolic HF by appraising the patient's:
Ejection fraction (EF)
The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?
Elevate the head of the bed.
A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?
Heart failure
The pathophysiology of pericardial effusion is associated with all of the following except:
Increased venous return.
The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?
Left ventricular function
Which feature is the hallmark of systolic heart failure?
Low ejection fraction (EF)
Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?
Monitor blood pressure frequently
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?
Pulmonary congestion
A client has been diagnosed with heart failure. What is the major nursing outcome for the client?
Reduce the workload on the heart.
Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?
Spironolactone
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?
The client says his rings have become tight and are difficult to remove.
The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding?
The woman may be experiencing an exacerbation of right-sided HF.
A critical care nurse is providing care for a patient who was admitted to the intensive care unit after going into cardiogenic shock while on one of the hospital's medical units. This nurse should plan assessments and interventions in the knowledge that the effects of cardiogenic shock primarily result from:
Tissue hypoperfusion
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?
Titrate oxygen therapy.
The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure?
ascites
A client with heart failure is prescribed an angiotensin converting enzyme (ACE) inhibitor. When teaching the client about this medication, the nurse would explain that this class of medications are effective because they:
cause vasodilation to reduce the heart's workload.
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
A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?
echocardiogram
A nurse is conducting a teaching session about heart failure for a group of older adults who are at risk for this condition. When describing the underlying mechanisms for the development of heart failure, which concept would the nurse most likely include? Select all that apply.
fluid overload inadequate tissue perfusion
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?
heart failure
A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber?
heart rate of 55 beats per minute
The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed?
heart transplant
A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?
mask
A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis?
orthopnea
A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective?
peripheral edema
A nurse suspects that a client has digoxin toxicity. The nurse should assess for:
vision changes.
