Flashcards in Chapter 37 Deck (39):
A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect?
a. A decrease in blood pressure and urine output
b. An increase in creatinine and extremity edema
c. An increase in heart rate and respiratory rate
d. A decrease in respirations and oxygen saturation
C: In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings.
A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change?
a. Increase in stroke volume
b. Decrease in tissue perfusion
c. Increase in oxygen saturation
d. Decrease in arterial vasoconstriction
B: In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. Stroke volume and oxygen saturation do not increase with a low ejection fraction.
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure?
a. Middle-aged woman with aortic stenosis
b. Middle-aged man with pulmonary hypertension
c. Older woman who smokes cigarettes daily
d. Older man who has had a myocardial infarction
A: Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.
The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure?
a. “I have been drinking more water than usual.”
b. “I have been awakened by the need to urinate at night.”
c. “I have to stop halfway up the stairs to catch my breath.”
d. “I have experienced blurred vision on several occasions.”
C: Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or “catching their breath.” This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.
A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client?
a. “Please come into the clinic for an evaluation.”
b. “Increase your fluid intake during waking hours.”
c. “Use an over-the-counter cough suppressant.”
d. “Sleep on two pillows to facilitate postnasal drainage.”
A: The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible.
The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure?
a. “I sleep with four pillows at night.”
b. “My shoes fit really tight lately.”
c. “I wake up coughing every night.”
d. “I have trouble catching my breath.”
B: Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.
The nurse notes that the client’s apical pulse is displaced to the left. What conclusion can be drawn from this assessment?
a. This is a normal finding.
b. The heart is hypertrophied.
c. The left ventricle is contracted.
d. The client has pulsus alternans.
B: The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left
The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse’s best intervention?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the health care provider immediately.
d. Transfer the client to the intensive care unit.
A: The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.
A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse’s best response?
a. “Weight is the best indication that you are gaining or losing fluid.”
b. “Daily weights will help us make sure that you’re eating properly.”
c. “The hospital requires that all inpatients be weighed daily.”
d. “You need to lose weight to decrease the incidence of heart failure.”
A: Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.
A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse’s best action?
a. Place the client in a high Fowler’s position.
b. Begin cardiopulmonary resuscitation (CPR).
c. Promote rest and minimize activities.
d. Administer loop diuretics as prescribed.
D: The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler’s position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.
A client with heart failure is experiencing acute shortness of breath. What is the nurse’s priority action?
a. Place the client in a high Fowler’s position.
b. Perform nasotracheal suctioning of the client.
c. Auscultate the client’s heart and lung sounds.
d. Place the client on a 1000 mL fluid restriction.
A: Placing a client in a high Fowler’s position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client’s heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed.
A client with heart failure is prescribed enalapril (Vasotec). What is the nurse’s priority teaching for this client?
a. “Avoid using salt substitutes.”
b. “Take your medication with food.”
c. “Avoid using aspirin-containing products.”
d. “Check your pulse daily.”
A: Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.
The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client?
a. Administer this medication before meals to aid absorption.
b. Instruct the client to ask for assistance when arising from bed.
c. Give the medication with milk to prevent stomach upset.
d. Monitor the potassium level and check for symptoms of hypokalemia.
B: Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension.
The client who just started taking isosorbide dinitrate (Isordil) reports a headache. What is the nurse’s best action?
a. Titrate oxygen to relieve headache.
b. Hold the next dose of Isordil.
c. Instruct the client to drink water.
d. Administer PRN acetaminophen.
D: The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen.
The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention?
a. Insert an indwelling urinary catheter.
b. Monitor the client’s blood pressure.
c. Place the nitroglycerin under the client’s tongue.
d. Monitor the client’s serum glucose level.
B: Intravenous nitroglycerin and morphine will decrease the client’s blood pressure, so it is important to monitor closely for hypotension. Intravenous medications are not administered under the tongue. Although the client may need an indwelling urinary catheter to monitor output, it is not the priority. The client’s glucose levels should not be affected by these medications.
The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client?
a. “Avoid taking aspirin or aspirin-containing products.”
b. “Increase your intake of foods high in potassium.”
c. “Hold this medication if your pulse rate is below 80 beats/min.”
d. “Do not take this medication within 1 hour of taking an antacid.”
D: Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.
A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse?
c. Pulse of 62 beats/min
d. Potassium of 2.9 mEq/L
D: Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headache may occur with any medication and is not a serious side effect. Bradycardia is not likely to occur with this medication.
The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client’s activity?
a. Decrease in oxygen saturation from 98% to 95%
b. Respiratory rate change from 22 to 28 breaths/min
c. Systolic blood pressure change from 136 to 96 mm Hg
d. Increase in heart rate from 86 to 100 beats/min
C: A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.
The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication?
c. Sacral edema
d. Irregular heart rate
A: Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. Dysphagia, sacral edema, and an irregular heart rate are not related to pulmonary edema.
A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure?
a. “Avoid drinking more than 3 quarts of liquids each day.”
b. “Eat six small meals daily instead of three larger meals.”
c. “When you feel short of breath, take an additional diuretic.”
d. “Weigh yourself daily while wearing the same amount of clothing.”
D: Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.
A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse’s priority intervention?
a. Assess respiratory status.
b. Monitor electrolyte levels.
c. Administer intravenous fluids.
d. Insert a Foley catheter.
A: Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously.
The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client’s stenosis has progressed?
a. Oxygen saturation of 92%
b. Dyspnea on exertion
c. Muted systolic murmur
d. Upper extremity weakness
B: Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases.
The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client?
a. Bounding arterial pulse
b. Slow, faint arterial pulse
c. Narrowed pulse pressure
d. Elevated systolic pressure
C: In aortic stenosis, the client presents with narrowed pulse pressure when blood pressure (BP) is assessed.
A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse’s best response?
a. “The prosthetic valve places you at greater risk for a heart attack.”
b. “Blood clots form more easily in artificial replacement valves.”
c. “The vein taken from your leg reduces circulation in the leg.”
d. “The surgery left a lot of small clots in your heart and lungs.”
B: Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots.
The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education?
a. “I will be able to carry heavy loads after 6 months of rest.”
b. “I will have my teeth cleaned by the dentist in 2 weeks.”
c. “I will avoid eating foods high in vitamin K, like spinach.”
d. “I will use an electric razor instead of a straight razor to shave.”
B: Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics.
The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about?
a. Family history of coronary artery disease
b. Recent travel to Third World countries
c. Pet ownership, especially cats with litter boxes
d. History of a systemic infection within the past month
D: The clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. Assessing for coronary artery disease, recent travel, or pet ownership is not related to endocarditis.
The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use?
a. Standard Precautions
b. Bleeding Precautions
c. Reverse isolation
d. Contact isolation
A: The client with infective endocarditis does not pose any specific threat of transmitting the causative organism.
A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client?
a. Heart rate that speeds up and slows down
b. Friction rub at the left lower sternal border
c. Presence of a regularly gallop rhythm
d. Coarse crackles in bilateral lung bases
B: The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.
The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include?
a. “Take your digoxin at the same time every day.”
b. “You should begin an aerobic exercise program.”
c. “You should report episodes of dizziness or fainting.”
d. “You may have only two alcoholic drinks daily.”
C: The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM.
The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority?
a. Rapid position changes can create shear and friction forces, which can tear out internal vascular sutures.
b. The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure.
c. The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes.
d. The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.
C: Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period.
A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client’s discharge instructions?
a. “Use a soft-bristled toothbrush and avoid flossing.”
b. “Avoid large crowds and people who are sick.”
c. “Change positions slowly to avoid hypotension.”
d. “Check your heart rate before taking the medication.”
B: These agents cause immune suppression, leaving the client more vulnerable to infection.
A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, “I know a transplant is my last chance, but I don’t want to become a vegetable.” What is the nurse’s best response?
a. “Would you like to speak with a priest or chaplain?”
b. “I will consult a psychiatrist to speak with you.”
c. “Do you want to come off the transplant list?”
d. “Would you like information about advance directives?”
D: The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future.
The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client’s activity level?
a. “Do you have trouble breathing or chest pain?”
b. “Are you able to walk upstairs without fatigue?”
c. “Do you awake with breathlessness during the night?”
d. “Do you have new-onset heaviness in your legs?”
B: Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client’s activity is the same or worse, or whether the client identifies a decrease in activity level.
An older adult client with heart failure states, “I don’t know what to do. I don’t want to be a burden to my daughter, but I can’t do it alone. Maybe I should die.” What is the nurse’s best response?
a. “Would you like to talk about this more?”
b. “You’re lucky to have such a devoted daughter.”
c. “You must feel as though you are a burden.”
d. “Would you like an antidepressant medication?”
A: Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly.
An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority?
b. Chest x-ray
c. T4 and thyroid-stimulating hormone (TSH)
d. Arterial blood gas
A: Echocardiography is considered the best tool for the diagnosis of heart failure. A chest x-ray probably will be done, and if the client has dyspnea, an arterial blood gas will be drawn, but the echocardiogram is the priority. T4 and TSH might be ordered to assess for a contributing cause of heart failure.
The nurse is caring for a client with severe heart failure. What is the best position in which to place this client?
a. High Fowler’s, pillows under arms
b. Semi-Fowler’s, with legs elevated
c. High Fowler’s, with legs elevated
d. Semi-Fowler’s, on the left side
A: Placing the client in high Fowler’s position, with pillows under the arms, allows for maximum chest expansion.
The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction?
a. “Walk until you become short of breath and then walk back home.”
b. “Gather everything you need for a chore before you begin.”
c. “Pull rather than push or carry items heavier than 5 pounds.”
d. “Take a walk after dinner every day to build up your strength.”
B: Gathering all supplies needed for a chore at one time decreases the amount of energy needed.
A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse’s best action?
a. Administer the Vasotec.
b. Recheck the blood pressure.
c. Hold the Vasotec.
d. Notify the health care provider.
A: The nurse should administer the medication. Generally, the health care provider will maintain the client’s blood pressure between 90 and 110 mm Hg.