MED SURG PREP U 29
A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be?
30% Explanation: The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure.The normal EF is 55%-65%. An EF of 5% is not life sustaining and an EF of 30% is about half the normal percentage.
A client has had an echocardiogram to measure ejection fracton. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?
55% Explanation: Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.
A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered?
An echocardiogram Explanation: Increasing shortness of breath (dyspnea) and fatigue are common signs of left-sided heart failure (HF). However, some of the physical signs that suggest HF may also occur with other diseases, such as renal failure and chronic obstructive pulmonary disease; therefore, diagnostic testing is essential to confirm a diagnosis of HF. Assessment of ventricular function is an essential part of the initial diagnostic workup. An echocardiogram is usually performed to determine the ejection fraction, identify anatomic features such as structural abnormalities and valve malfunction, and confirm the diagnosis of HF.
A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing intervention?
Assess oxygen saturation Explanation: Assessment is priority to determine the severity of the exacerbation. It is important to assess the oxygen saturation in a client with heart failure because below-normal oxygen saturation can be life-threatening. Treatment options vary according to the severity of the client's condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve symptoms and reduce the workload on the heart by reducing afterload and preload.
A health care provider in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours Explanation: Pitting edema is documented as a +1 when a depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
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 Explanation: The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minuteis within normal range as well as the blood pressure and oxygen saturation.
A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?
Call for a chest x-ray. Explanation: A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.
A client is brought to the emergency department via rescue squad with suspicion of cardiogenic pulmonary edema. What complication should the nurse monitor for? Select all that apply.
Cardiac dysrhythmias Respiratory arrest Cardiac arrest Explanation: Pulmonary edema is fluid accumulation in the lungs, which interferes with gas exchange in the alveoli. It represents an acute emergency and is a frequent complication of left-sided heart failure. Cardiac dysrhythmias and cardiac or respiratory arrest are associated complications. Nausea and vomiting are not complications but are symptoms of many disorders. The client is not at increased risk for the development of pulmonary embolism with pulmonary edema.
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) Explanation: A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade.
A client is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client?
Digoxin immune FAB Explanation: Digibind binds with digoxin and makes it unavailable for use. The digibind dosage is based on the digoxin level and the patient's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.
Which medication reverses digitalis toxicity?
Digoxin immune FAB Explanation: Digoxin immune FAB binds with digoxin and makes it unavailable for use. The dosage is based on the digoxin concentration and the client's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.
Which is a cerebrovascular manifestation of heart failure?
Dizziness Explanation: Cerebrovascular manifestations of heart failure include dizziness, lightheadedness, confusion, restlessness, and anxiety. Tachycardia is a cardiovascular manifestation. Ascites is a gastrointestinal manifestation. Nocturia is a renal manifestation.
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?
Dizziness Explanation: Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion include dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.
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 Explanation: Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia.
The diagnosis of heart failure is usually confirmed by which of the following?
Echocardiogram Explanation: Although the chest X-ray can indicate cardiomegaly and the ECG can indicate a left ventricular abnormality, it is the echocardiogram that is diagnostic. This test measures ejection fraction (EF) which, if greater than 40% and accompanied with signs and symptoms of heart failure, indicates diastolic dysfunction and impaired ventricular relaxation.
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
Echocardiogram Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.
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 Explanation: The heart?'s ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm corpulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart?s conduction system.
A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, bradycardia, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence?
Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. Explanation: The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).
he nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience?
Gradual unexplained weight gain Explanation: Clients with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention. Left-sided heart failure produces paroxysmal nocturnal dyspnea, which may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Right-sided heart failure does not cause increased perspiration or increased urine output.
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 Explanation: Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the client's weight on the shoulder muscles.
The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity. Under what classification does the nurse understand this patient would be categorized?
II Explanation: Classification II of heart failure is indicated by the patient being comfortable at rest, but experiencing fatigue, palpitation, or dyspnea during ordinary physical activity.
Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?
IV Explanation: Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In class II, ADLs are slightly limited. In class III, ADLs are markedly limited.
A patient seen in the clinic has been diagnosed with stage A heart failure (according to the staging classification of the American College of Cardiology [ACC]). What education will the nurse provide to this patient?
Information about ACE inhibitors and risk factor reduction Explanation: Teaching for patients with stage A heart failure should include information about risk factor control and use of ACE inhibitors. Beta blockers pertain to stages B-D, and diuretics implantable cardioverters/defibrillators to stages C-D.
A client in the hospital informs the nurse he "feels like his heart is racing and can't catch his breath." What does the nurse understand occurs as a result of a tachydysrhythmia?
It reduces ventricular ejection volume. Explanation: Reducing ventricular ejection volume because diastole, during which the ventricle fills withblood (preload), is shortened as a result of a tachydsrhythmia. Causing a loss of elasticity in the muscle is a result of cardiomyopathy. Afterload is decreased not increased.
A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?
JVD is noted 4 cm above the sternal angle. Explanation: JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.
A new client has been admitted with right-sided heart failure. When assessing this client, the nurse knows to look for which finding?
Jugular venous distention Explanation: When the right ventricle cannot effectively pump blood from the ventricle into the pulmonary artery, the blood backs up into the venous system and causes jugular venous distention and congestion in the peripheral tissues and viscera. All the other choices are symptoms of left-sided heart failure.
Which feature is the hallmark of systolic heart failure?
Low ejection fraction (EF) Explanation: A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?
Low-sodium diet Explanation: Medical management of both left-sided and right-sided heart failure is directed at reducing the heart?s workload and improving cardiac output primarily through dietary modifications, drug therapy, and lifestyle changes. A low-sodium diet is prescribed, and fluids may be restricted. Because the client will be on a diuretic such as Lasix, he may become potassium depleted and would need potassium in the diet. A low-cholesterol and low-fat diet may be ordered but are not specific to the heart failure.
A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate?
Morphine sulfate Explanation: Morphine seems to help relieve respiratory symptoms by depressing higher cerebral centers, thus relieving anxiety and slowing respiratory rate. Morphine also promotes muscle relaxation and reduces the work of breathing. Furosemide is a loop diuretic and will decrease fluid accumulation but will not reduce anxiety. Nitroglycerin will promote smooth muscle relaxation in the vessel walls and will relieve pain but not reduce anxiety. Dopamine is an inotrope that will increase the force of ventricular contraction but will not alleviate anxiety.
Which describes difficulty breathing when a client is lying flat?
Orthopnea Explanation: Orthopnea occurs when the client is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.
Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?
Preload Explanation: Preload is the the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from a ventricle. The ejection fraction is the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole. Stroke volume is the amount of blood pumped out of the ventricle with each contraction.
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 Explanation: When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.
A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.)
Pulmonary crackles Dyspnea Cough Explanation: The clinical manifestations of pulmonary congestion associated with left-sided heart failure include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels, but not ascites or jugular vein distention.
A client has been diagnosed with heart failure. What is the major nursing outcome for the client?
Reduce the workload on the heart. Explanation: Specific objectives of medical management of heart failure include reducing the workload on the heart by reducing preload and afterload. The other choices are objectives that may be supportive of a healthy lifestyle, but are not specific to a client with heart failure.
A client with heart failure reports a sudden change in the ability to perceive colors. The client reports nausea, and assessment reveals an irregular pulse of 39 beats per minute. What is the nurse's best action?
Report the possibility of digitalis toxicity to the care provider promptly Explanation: This client's presentation is characteristic of digitalis toxicity, which must be promptly reported. This constellation of symptoms is less likely to result from furosemide. Close monitoring is necessary; vital signs every 30 minutes is insufficient. Referrals are not the most time-dependent priority.
The nurse recognizes which symptom as a classic sign of cardiogenic shock?
Restlessness and confusion Explanation: Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).
Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?
Spironolactone Explanation: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide diuretic is Diuril. Bumetanide and ethacrynic acid are loop diuretics.
Which is a classic sign of cardiogenic shock?
Tissue hypoperfusion Explanation: Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation). Low blood pressure is a classic sign of cardiogenic shock. Hypoactive bowel sounds are classic signs of cardiogenic shock. Decreased urinary output is a classic sign of cardiogenic shock.
The student nurse is caring for a client with heart failure. Diuretics have been ordered. What method might be used with a debilitated client to help the nurse evaluate the client''s response to diuretics?
Using a urinary catheter Explanation: To evaluate response to diuretics, a urinary catheter is used. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. A biventricular pacemaker is used to sustain life.
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?
Valsartan (Diovan) Explanation: Valsartan (Diovan) is the only angiotensin receptor blocker listed. Digitalis/digoxin (Lanoxin) is a cardiac glycoside. Metolazone (Zaroxolyn) is a thiazide diuretic. Carvedilol (Coreg) is a beta-adrenergic blocking agent (beta-blocker).
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?
Weighing the client daily at the same time each day Explanation: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.
The nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will decrease preload?
administration of a vasodilating drug (as ordered by a health care provider) Explanation: Preload is the amount of blood presented to the ventricles just before systole. Anything that decreases the amount of blood returning to the heart will decrease preload, such as vasodilation or blood pooling in the extremities. Anything that assists in returning blood to the heart (antiembolytic stockings) or preventing blood from pooling in the extremities will increase preload.
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:
canned peas. Explanation: There is a wide variety of foods that the client can still eat; the key is to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. It is important to read food labels and look for foods that contain less than 300 mg sodium/serving.
A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing
decompensated heart failure with pulmonary edema. Explanation: Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated heart failure with pulmonary edema. These signs can be confused with pneumonia and tuberculosis, however the patient reveals course crackles upon auscultation which is indicitive of pulmonary edema. A patient with acute COPD would have diminished lung sounds bilaterally.
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 Explanation: A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.
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 Explanation: Pulmonary edema is an acute event that results from heart failure. Myocardial scarring, resulting from ischemia, limits the distensibility of the ventricle, making it vulnerable to demands for increased workload. When the demand on the heart increases, there is resistance to left ventricular filling and blood backs up into the pulmonary circulation. Pulmonary edema quickly develops.
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 Explanation: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan, not an electrocardiogram or cardiac ultrasound. Cardiac catheterization is not the diagnostic tool for this measurement.
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 Explanation: Loop diuretics such as furosemide, bumetanide, and torsemide are the preferred first-line diuretics because of their efficacy in patients with and without renal impairment. Spironolactone is a potassium diurectic. Mannitol is an osmotic diuretic not used for heart failure. Metolazone is a potassium diuretic not used for first treament for heart failure. Diuretics should never be used alone to treat HF because they don't prevent further myocardial damage.
The nurse is asssessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion?
inadequate cardiac output Explanation: Pulmonary congestion occurs and tissue perfusion is compromised and diminished when the heart, primarily the left ventricle, cannot pump blood out of the ventricle effectively into the aorta and the systemic circulation. Ascites is fluid in the abdomen, not a cause of congestion. Hepatomegaly is an enlarged liver, which does not cause crackling breath sounds. Nocturia, or voiding at night, does not cause crackling breath sounds.
The nurse is caring for a client with heart failure who is receiving torsemide. What implementation will help the nurse evaluate the client's response of the medication?
measuring intake and output Explanation: To evaluate response to torsemide, which is a diuretic, intake and output are monitored. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. Asking the client about comfort level will not assess urinary output.
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 Explanation: Clients with acute pulmonary edema experience sudden dyspnea, wheezing, orthopnea, cough, cyanosis, and tachycardia. Respirations sound moist or gurgling. Drowsiness and numbness are not considered issues. Increased cardiac output is not part of this checklist. Hypertension is not an immediate symptom.
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?
nausea and vomiting Explanation: Digitalis medications are potent and may cause various toxic effects. The nurse should monitor the client for signs of digitalis toxicity, not just during the initial period of therapy, but throughout care management. The most common signs and symptoms include nausea and vomiting which can lead to dehydration and electrolyte imbalance. Symptoms of toxicity do not include vasculitis, flexion contractures, or enlargement of joints.
When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating
orthopnea. Explanation: Clients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler position. Dyspnea upon exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.
A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective?
peripheral edema Explanation: Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.
The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure?
pitting edema Explanation: The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response. Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a thickened left ventricle, seen with aortic stenosis or hypertension. The decreased oxygen saturation levels are from hypoexemia.
The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity?
potassium level of 2.8 mEq/L Explanation: Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.
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
pulmonary embolism. Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.
The nurse finds a client unresponsive in the hospital room and calls a cardiac arrest. Which health care professionals will be responsible for an insertion of the endotracheal tube during the cardiac arrest? Select all that apply.
respiratory therapist nurse anesthetist physician Explanation: Respiratory therapists, physicians, and nurse anesthetists can place an endotracheal airway during cardiac arrest in a hospital. Nurses and paramedics may insert endotracheal tubes in the community setting (field), but not in the hospital.
A nurse suspects that a client has digoxin toxicity. The nurse should assess for:
vision changes. Explanation: Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.
