Ch 29 – Flashcards

A client diagnosed with heart failure presents with the following assessment data: temperature 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; pulse oximeter reading of 89%. Following the completion of your assessment, you prioritize your findings. Which findings indicate a need for immediate attention? a) Blood pressure b) Lung congestion c) Nausea d) Temperature

The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock? a) Restlessness and confusion b) Hyperactive bowel sounds c) High blood pressure d) Increased urinary output

The Cardiac Nurse Clinician is teaching a group of clients with heart failure about self-management of their disease. What dietary advice should the Nurse Clinician give to clients with severe heart failure until edema resolves? a) Encourage increased intake of red meat. b) Avoid the intake of canned fruit and fruit juices. c) Avoid the intake of processed and commercially prepared foods. d) Encourage increased intake of vegetables with natural sodium.

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating which of the following? a) Hyperpnea b) Dyspnea on exertion c) Orthopnea d) Paroxysmal nocturnal dyspnea

Which of the following is the primary cause of pulmonary or peripheral congestion? a) Nocturia b) Inadequate cardiac output c) Ascites d) Hepatomegaly

You are working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for you to closely monitor an older adult receiving digitalis preparations for cardiac disorders? a) Older adults are at increased risk for cardiac arrests. b) Older adults are at increased risk for asthma. c) Older adults are at increased risk for toxicity. d) Older adults are at increased risk for hyperthyroidism.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? a) BUN b) Echocardiogram c) Serum electrolytes d) Electrocardiogram (ECG)

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? a) Echocardiogram b) A pulmonary arteriography c) A chest radiograph d) Electrocardiogram

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? a) The client says that he has been urinating less frequently at night. b) The client says he has been hungry in the evening. c) The client says he is short of breath when ambulating. d) The client says his rings have become tight and are difficult to remove.

A physician in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema? a) Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours b) Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours c) A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling d) A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling

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? a) Class II (Mild) b) Class III (Moderate) c) Class I (Mild) d) Class IV (Severe)

When assessing a client with left-sided heart failure, the nurse expects to note: a) ascites. b) air hunger. c) pitting edema of the legs. d) jugular vein distention.

A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals: a) peripheral edema. b) skin rash. c) dry cough. d) postural hypotension.

A patient with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, bradycardia, and muffled heart sounds. The senior nursing student recognizes these symptoms occur when a) Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. b) Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction. c) The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. d) The pericardial space is eliminated with scar tissue and thickened pericardium.

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is: a) weight. b) fluid intake and output. c) vital signs. d) urine specific gravity.

Which of the following body system responses correlates with systolic heart failure (HF)? a) Increased blood volume ejected from ventricle b) Decrease in renal perfusion c) Dehydration d) Vasodilation of skin

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? a) Bibasilar crackles b) Right upper quadrant pain c) Dependent edema d) Jugular vein distention

Which of the following is the hallmark of systolic heart failure? a) Basilar crackles b) Limitation of activities of daily living (ADLs) c) Low ejection fraction (EF) d) Pulmonary congestion

A 73-year-old client has been admitted to the cardiac step-down unit where you practice nursing. After diagnostics, she was brought to your unit with acute pulmonary edema. Which of the following symptoms would you expect to find during your assessment? a) Drowsiness, numbness b) Hypertensive c) Moist, gurgling respirations d) Increased cardiac output

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) Digoxin (Lanoxin) b) Carvedilol (Coreg) c) Metolazone (Zaroxolyn) d) Valsartan (Diovan)

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)? a) Chlorothiazide (Diuril) b) Ethacrynic acid (Edecrin) c) Spironolactone (Aldactone) d) Bumetanide (Bumex)

Which of the following medications is a human brain natriuretic peptide (BNP) preparation? a) Captopril b) Enalapril c) Natrecor d) Metoprolol

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? a) Bilateral crackles b) Leg edema c) Productive cough d) Cyanosis of the lips

The nurse is preparing to administer furosemide (Lasix) to a client with severe heart failure. What lab study should be of most concern for this client while taking Lasix? a) BNP of 100 b) Hemoglobin of 12 c) Potassium level of 3.1 d) Sodium level of 135

A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth daily, and furosemide (Lasix), 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause: a) nocturia and sleep disturbances. b) taste and smell alterations. c) dry mouth and urine retention. d) visual disturbances.

A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure? a) Complete blood count (CBC) b) B-type natriuretic peptide (BNP) c) Serum electrolytes d) Blood urea nitrogen (BUN)

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? a) Attach a pulse oximeter probe and obtain values. b) Observe for mist in the endotracheal tube. c) Call for a chest x-ray. d) Listen for breath sounds over the epigastrium.

On assessment, the nurse knows that a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity would have heart failure classified as Stage: a) A b) B c) D d) C

A nurse suspects that a client has digoxin toxicity. The nurse should assess for: a) decreased urine output. b) hearing loss. c) vision changes. d) gait instability.

A physician orders digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? a) Sodium level of 152 mEq/L b) Magnesium level of 2.5 mg/dl c) Potassium level of 2.8 mEq/L d) Calcium level of 7.5 mg/dl

A nurse taking care of a patient recently admitted to the ICU observes the patient coughing up large amounts of pink, frothy sputum. Auscultation of the lungs reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this patient is developing which of the following problems? a) Tuberculosis b) Bilateral pneumonia c) Acute exacerbation of chronic obstructive pulmonary disease d) Decompensated heart failure with pulmonary edema

A patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention? a) Administer angiotensin-converting enzyme inhibitors b) Administer diuretics c) Assess oxygen saturation level d) Administer angiotensin II receptor blockers

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? a) Left atrial function b) Left ventricular function c) Right atrial function d) Right ventricular function

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement? a) "I sleep on three pillows each night." b) "I don't have the same appetite I used to." c) "My pants don't fit around my waist." d) "My feet are bigger than normal."

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? a) Low-sodium diet b) Low-cholesterol diet c) Low-potassium diet d) Low-fat diet

The nurse is preparing to administer hydralazine and isosorbide dinitrate (Dilatrate). When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse? a) Hold the medication and call the physician. b) Administer the hydralazine and hold the dinitrate. c) Administer a saline bolus of 250 mL and then administer the medication. d) Administer the medication and check the blood pressure in 30 minutes.

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which of the following assessment findings for this client? a) Jugular venous distention b) Nausea c) Pulmonary congestion d) Pedal edema

Eighty six-year-old Susan Matthews has been rushed to the ED with pulmonary edema during your shift. She is going to need oxygen immediately. Which oxygen delivery system do you use first? a) Mechanical ventilation b) Intubation c) A mask d) A nasal cannula

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of: a) acute pulmonary edema. b) right-sided heart failure. c) cardiogenic shock. d) pneumonia.