Prepu ch28 p2
The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home?
"I'm having trouble going up the steps during the day."
A patient has been newly diagnosed with heart failure (HF) and has come to the meet with the nurse at the clinic for health education. What lifestyle recommendation should the nurse provide to this patient when discussing dietary modifications?
"It's in your best interests to avoid excessive fluids and sodium in your diet."
The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?
Avoid positioning the client supine.
The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure?
Brain natriuretic peptide (BNP)
The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition?
Crackles are audible on chest auscultation.
The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis?
Distended neck veins
A client has been having cardiac symptoms for several months and is seeing a cardiolozist for diagnostics to determine the cause, How will the client's ejection fraction be measured?
Echocardiogram
A patient has been prescribed a digitalis preparation for heart failure. What should the nurse closely monitor when caring for this client?
Electrolyte and water loss
Which New York Heart Association classification of heart failure (HF) has a poor prognosis and includes symptoms of cardiac insufficiency at rest?
IV
Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?
IV 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 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.
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
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
A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?
acute pulmonary edema
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:
canned peas
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
echocardiogram
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
The nurse recognizes that an older adult patient with heart failure is experiencing the effects of inadequate cardiac output, a problem that affects many of the body's systems. Inadequate perfusion of the patient's kidneys leads to which of the following pathophysiological effects?
increased renin release
Which is a characteristic of right-sided heart failure?
jugular vein distention
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
The client with cardiac failure is taught to report which symptom to the health care provider or clinic immediately?
persistent cough
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
The nurse notes that a client has developed dyspnea; a productive, mucoid cough; peripheral cyanosis; and noisy, moist-sounding, rapid breathing. These signs and symptoms suggest which health problem?
pulmonary edema
A client has been diagnosed with heart failure. What is the major nursing outcome for the client?
reduce the workload of the heart
A nurse is administering nitroglycerin, which decreases afterload and preload. Afterload refers to which of the following?
the amount of resistance to ejection of blood from the ventricles
