UNIT 4: Management of Patients with complications from Heart Disease

Question 1

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?
A. Pericarditis
B. Cardiomyopathy
C. Pulmonary edema
D. Right ventricular hypertrophy

Answer 1

ANS: C
Rationale: As a result of decreased cerebral oxygenation, the client with pulmonary
edema becomes increasingly restless and anxious. Along with a sudden onset of
breathlessness and a sense of suffocation, the client’s hands become cold and moist, the
nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak
and rapid, and the neck veins are distended. Incessant coughing may occur, producing
increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and
cardiomyopathy do not involve wet breath sounds or mucus production.

Question 2

The triage nurse in the emergency department is assessing a client with chronic heart
failure who has presented with worsening symptoms. In reviewing the client’s medical
history, which condition is a potential primary cause of the client’s heart failure?
A. Endocarditis
B. Pleural effusion
C. Atherosclerosis
D. Atrial septal defect

Answer 2

ANS: C
Rationale: Atherosclerosis of the coronary arteries is the primary cause of heart failure.
Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that
contribute to the etiology of heart failure.

Question 3

The nurse is assessing an older adult client with numerous health problems. Which
assessment finding indicates an increase in the client’s risk for heart failure?
A. The client takes furosemide 20 mg/day.
B. The client’s potassium level is 4.7 mEq/L.
C. The client is white.
D. The client’s age is greater than 65.

Answer 3

ANS: D
Rationale: Heart failure is the most common reason for hospitalization of people older
than 65 years of age and is the second-most common reason for visits to a physician’s
office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an
increased risk for heart failure. The fact that the client takes furosemide 20 mg/day does
not indicate an increased risk for heart failure, although this drug is often used in the
treatment of heart failure. The client being white indicates a decreased risk for heart
failure compared with Black and Hispanic clients.

Question 4

The nurse is caring for a client who is receiving a loop diuretic for the treatment of
heart failure. What assessment should the nurse prioritize?
A. Monitoring liver function studies
B. Blood pressure
C. Vitamin D intake
D. Monitoring potassium levels

Answer 4

ANS: B
Rationale: Diuretic therapy increases urine output and decreases blood volume, which
places the client at risk of hypotension. Clients are at risk of losing potassium with loop
diuretic therapy and need to continue with potassium in their diet; hypokalemia is a
consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D
intake is not relevant.

Question 5

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?
A. Pulmonary edema
B. Distended neck veins
C. Dry cough
D. Orthopnea

Answer 5

ANS: B
Rationale: Right-sided heart failure may manifest by distended neck veins, dependent
edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness.
The other answers are not characteristic signs of right-sided heart failure.

Question 6

A nurse in the critical care unit is caring for a client with heart failure who has
developed an intracardiac thrombus. The nurse should assess for signs and symptoms of
which sequela?
A. Stroke
B. Myocardial infarction (MI)
C. Hemorrhage
D. Peripheral edema

Answer 6

ANS: A
Rationale: Intracardiac thrombi can become lodged in the cerebral vasculature, causing
stroke. There is no direct risk of MI, hemorrhage, or peripheral edema

Question 7

The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In
addition to physical assessment, the nurse should monitor what assessment information?
A. Skin turgor
B. Potassium level
C. White blood cell count
D. Peripheral pulses

Answer 7

ANS: B
Rationale: The serum potassium level is monitored because the effect of digoxin is
enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor,
white cell levels, and peripheral pulses are not normally affected in cases of digitalis
toxicity.

Question 8

The triage nurse in the emergency department is performing a rapid assessment of a
client with reports of severe chest pain and shortness of breath. The client is diaphoretic,
pale, and weak. When the client collapses, which action would the nurse take first?
A. Check for a carotid pulse.
B. Apply supplemental oxygen.
C. Give two full breaths.
D. Gently shake and shout, “Are you OK?”

Answer 8

ANS: D
Rationale: Assessing responsiveness is the first step in basic life support. Opening the
airway and checking for respirations should occur next. If breathing is absent, two
breaths should be given, usually accompanied by supplementary oxygen. Circulation is
checked by palpating the carotid artery.

Question 9

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?
A. Right-sided heart failure
B. Acute pulmonary edema
C. Pneumonia
D. Cardiogenic shock

Answer 9

ANS: B
Rationale: Because of decreased contractility and increased fluid volume and pressure in
clients with heart failure, fluid may be driven from the pulmonary capillary beds into the
alveoli, causing pulmonary edema and signs and symptoms described. In right-sided
heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral
edema. In pneumonia, the client would have a temperature spike, and sputum that
varies in color. Cardiogenic shock would show signs of hypotension and tachycardia

Question 10

A client admitted to the medical unit with heart failure is exhibiting signs and
symptoms of pulmonary edema. How should the nurse best position the client?
A. In a high Fowler position
B. On the left side-lying position
C. In a flat, supine position
D. In the Trendelenburg position

Answer 10

ANS: A
Rationale: Proper positioning can help reduce venous return to the heart. The client is
positioned upright. If the client is unable to sit with the lower extremities dependent, the
client may be placed in an upright position in bed. The supine and Trendelenburg
positions will not reduce venous return, lower the output of the right ventricle, or
decrease lung congestion. Similarly, side-lying position does not promote circulation.

Question 11

The nurse has entered a client’s room and found the client unresponsive and not
breathing. What is the nurse’s next appropriate action?
A. Palpate the client’s carotid pulse.
B. Illuminate the client’s call light.
C. Begin performing chest compressions.
D. Activate the Emergency Response System (ERS).

Answer 11

ANS: D
Rationale: After checking for responsiveness and breathing, the nurse should activate the
ERS. Assessment of carotid pulse should follow and chest compressions may be
indicated. Illuminating the call light is an insufficient response.

Question 12

The nurse is providing discharge education to a client diagnosed with heart failure.
What should the nurse teach this client to do to assess fluid balance in the home setting?
A. Monitor and record blood pressure daily.
B. Monitor and record radial pulses daily.
C. Monitor weight daily.
D. Monitor bowel movements

Answer 12

ANS: C
Rationale: To assess fluid balance at home, the client should monitor daily weights at the
same time every day. Assessing radial pulses and monitoring the blood pressure may be
done, but these measurements do not provide information about fluid balance. Bowel
function is not indicative of fluid balance.

Question 13

The nurse is caring for an older adult client who has just returned from the operating
room (OR) after inguinal hernia repair. The OR report indicates that the client received
large volumes of IV fluids during surgery, and the client has a history of coronary artery
disease, increasing the risk for left-sided heart failure. Which signs and symptoms
indicating this condition would the nurse look for?
A. Jugular vein distention
B. Right upper quadrant pain
C. Bibasilar fine crackles
D. Dependent edema

Answer 13

ANS: C
Rationale: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular
fluid, or pressure overload. Jugular vein distention, right upper quadrant pain
(hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a
chronic condition.

Question 14

A client with heart failure is placed on a low-sodium diet. Which statement by the
client indicates that the nurse’s nutritional teaching plan has been effective?
A. “I will have a ham and cheese sandwich for lunch.”
B. “I will have a baked potato with broiled chicken for dinner.”
C. “I will have a tossed salad with cheese and croutons for lunch.”
D. “I will have chicken noodle soup with crackers and an apple for lunch.”

Answer 14

ANS: B
Rationale: The client’s choice of a baked potato with broiled chicken indicates that the
teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham,
cheese, and soup are often high in sodium.

Question 15

The nurse’s comprehensive assessment of a client who has heart failure includes
evaluation of the client’s hepatojugular reflux. What action should the nurse perform
during this assessment?
A. Elevate the client’s head to 90 degrees.
B. Press the right upper abdomen.
C. Press above the client’s symphysis pubis.
D. Lay the client flat in bed.

Answer 15

ANS: B
Rationale: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the
head of the bed at a 45-degree angle. As the right upper abdomen (the area over the
liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If
the internal jugular vein becomes distended, a client has positive hepatojugular reflux

Question 16

The nurse overseeing care in the ICU reviews the shift report on four clients. The
nurse recognizes which client to be at greatest risk for the development of cardiogenic
shock?
A. The client admitted with acute renal failure
B. The client admitted following an MI
C. The client admitted with malignant hypertension
D. The client admitted following a stroke

Answer 16

ANS: B
Rationale: Cardiogenic shock may occur following an MI when a large area of the
myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of
end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and
dysrhythmias. While clients with acute kidney injury are at risk for dysrhythmias and
clients experiencing a stroke are at risk for thrombus formation, the client admitted
following an MI is at the greatest risk for development of cardiogenic shock when
compared with the other listed diagnoses.

Question 17

When assessing the client with pericardial effusion, the nurse will assess for pulsus
paradoxus. Pulsus paradoxus is characterized by what assessment finding?
A. A diastolic blood pressure that is lower during exhalation
B. A diastolic blood pressure that is higher during inhalation
C. A systolic blood pressure that is higher during exhalation
D. A systolic blood pressure that is lower during inhalation

Answer 17

ANS: D
Rationale: Systolic blood pressure that is markedly lower during inhalation is called
pulsus paradoxus. The difference in systolic pressure between the point that is heard
during exhalation and the point that is heard during inhalation is measured. Pulsus
paradoxus exceeding 10 mm Hg is abnormal.

Question 18

The cardiac monitor alarm alerts the critical care nurse that the client is showing no
cardiac rhythm on the monitor. The nurse’s rapid assessment suggests cardiac arrest. In
providing cardiac resuscitation documentation, how should the nurse describe this initial
absence of cardiac rhythm?
A. Pulseless electrical activity (PEA)
B. Ventricular fibrillation
C. Ventricular tachycardia
D. Asystole

Answer 18

ANS: D
Rationale: Cardiac arrest occurs when the heart ceases to produce an effective pulse and
circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart
rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present,
but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is
the only condition that involves the absolute absence of a heart rhythm.

Question 19

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?
A. Teach the client deep breathing and coughing exercises.
B. Administer supplemental oxygen at all times.
C. Limit the client’s activity level.
D. Avoid positioning the client supine

Answer 19

ANS: D
Rationale: Orthopnea is defined as difficulty breathing while lying flat. This is a possible
complication of heart failure and, consequently, the nurse should avoid positioning the
client supine. Oxygen supplementation may or may not be necessary and activity does
not always need to be curtailed. Deep breathing and coughing exercises do not directly
address this symptom.

Question 20

The nurse is planning the care of a client with heart failure. The nurse should identify
what overall goals of this client’s care? Select all that apply.
A. Improve functional status
B. Prevent endocarditis.
C. Extend survival.
D. Limit physical activity.
E. Relieve client symptoms.

Answer 20

ANS: A, C, E
Rationale: The overall goals of management of heart failure are to relieve the client’s
symptoms, to improve functional status and quality of life, and to extend survival.
Activity limitations should be accommodated, but reducing activity is not a goal.
Endocarditis is not a common complication of heart failure and preventing it is not a
major goal of care.

Question 21

A client with heart failure has met with the primary care provider and begun
treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client
begins treatment, the nurse would prioritize which assessment?
A. Blood pressure
B. Level of consciousness (LOC)
C. Nausea
D. Oxygen saturation

Answer 21

ANS: A
Rationale: Clients receiving ACE inhibitors are monitored for hypotension, hyperkalemia
(increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in clients
with heart failure, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not
normally cause nausea.

Question 22

The nurse is reviewing the medication administration record of a client diagnosed
with systolic heart failure. Which medication would the nurse anticipate administering to
this client?
A. A beta-adrenergic blocker
B. An antiplatelet aggregator
C. A calcium channel blocker
D. A nonsteroidal anti-inflammatory drug (NSAId)

Answer 22

ANS: A
Rationale: Several medications are routinely prescribed for systolic heart failure,
including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers,
antiplatelet aggregators, and NSAIDs are not commonly prescribed.

Question 23

The nurse is caring for a client with systolic heart failure whose previous adverse
reactions rule out the safe use of angiotensin-converting enzyme (ACE) inhibitors. The
nurse should anticipate that the prescriber may choose which combination of drugs?
A. Loop diuretic and antiplatelet aggregator
B. Loop diuretic and calcium channel blocker
C. Combination of hydralazine and isosorbide dinitrate
D. Combination of digoxin and normal saline

Answer 23

ANS: C
Rationale: A combination of hydralazine and isosorbide dinitrate may be an alternative
for clients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel
blockers, and normal saline are not typically prescribed

Question 24

A client with a diagnosis of heart failure is started on a beta-blocker. What is the
nurse’s priority role during gradual increases in the client’s dose?
A. Educating the client that symptom relief may not occur for several weeks
B. Stressing that symptom relief may take up to 4 months to occur
C. Making adjustments to each day’s dose based on the blood pressure trends
D. Educating the client about the potential changes in LOC that may result from the
drug

Answer 24

ANS: A
Rationale: An important nursing role during titration is educating the client about the
potential worsening of symptoms during the early phase of treatment and stressing that
improvement may take several weeks. Relief does not take 4 months, however. The
nurse monitors blood pressure, but changes are not made based on short-term
assessment results. Beta-blockers rarely affect LOC.

Question 25

The nurse is performing a physical assessment on a client suspected of having heart
failure. The presence of which sound would tend to confirm the suspicion for heart
failure?
A. An S3 heart sound
B. Pleural friction rub
C. Faint breath sounds
D. A heart murmur

Answer 25

ANS: A
Rationale: An S3 heart sound is a sign that the heart is beginning to fail and that increased
blood volume fills the ventricle with each beat. Heart failure does not normally cause a
pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence
of crackles or wheezes, but faint breath sounds are less characteristic of heart failure

Question 26

An older adult client with heart failure is being discharged home on an ACE inhibitor
and a loop diuretic. The client’s most recent vital signs prior to discharge include oxygen
saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of
94/59 mm Hg. When planning this client’s subsequent care, what nursing concern should
be identified?
A. Altered tissue perfusion risk related to arrhythmia
B. Excess fluid volume risk related to medication regimen
C. Altered breathing pattern risk related to hypoxia
D. Falls risk related to hypotension

Answer 26

ANS: D
Rationale: The combination of low BP, diuretic use, and ACE inhibitor use constitutes a
risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The client’s
medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all clients
with heart failure, but this is not in evidence for this client at this time

Question 27

Cardiopulmonary resuscitation has been initiated on a client who was found
unresponsive. When performing chest compressions, the nurse should do which of the
following actions?
A. Perform at least 100 chest compressions per minute.
B. Pause to allow a colleague to provide a breath every 10 compressions.
C. Pause chest compressions to allow for vital signs monitoring every 4 to 5
minutes.
D. Perform high-quality chest compressions as rapidly as possible.

Answer 27

ANS: A
Rationale: During CPR, the chest is compressed 2 inches at a rate of at least 100
compressions per minute. This rate is the resuscitator’s goal; the aim is not to give
compressions as rapidly as possible. Compressions are not stopped after 10
compressions to allow for a breath or for full vital signs monitoring

Question 28

The nurse is providing client education prior to a client’s discharge home after
treatment for heart failure. The nurse gives the client a home care checklist as part of the
discharge teaching. What should be included on this checklist?
A. Know how to recognize and prevent orthostatic hypotension.
B. Weigh yourself weekly at a consistent time of day.
C. Measure everything you eat and drink until otherwise instructed.
D. Limit physical activity to only those tasks that are absolutely necessary.

Answer 28

ANS: A
Rationale: Clients with heart failure should be aware of the risks of orthostatic
hypotension. Weight should be measured daily; detailed documentation of all forms of
intake is not usually required. Activity should be gradually increased within the
parameters of safety and comfort.

Question 29

The nurse is educating an 80-year-old client diagnosed with heart failure about the
medication regimen. Which instruction would the nurse give this client about the use of
oral diuretics?
A. Avoid drinking fluids for 2 hours after taking the diuretic.
B. Take the diuretic in the morning to avoid interfering with sleep.
C. Avoid taking the medication within 2 hours consuming dairy products.
D. Take the diuretic only on days when experiencing shortness of breath.

Answer 29

ANS: B
Rationale: Oral diuretics should be given early in the morning so that diuresis does not
interfere with the client’s nighttime rest. Discussing the timing of medication
administration is especially important for older adult clients who may have urinary
urgency or incontinence. The nurse would not teach the client about the timing of fluid
intake. Fluid intake does not need to be adjusted and dairy products are not
contraindicated.

Question 30

The nurse is creating a care plan for a client diagnosed with heart failure. When
addressing the problem of anxiety, what interventions should the nurse include in the
care plan? Select all that apply.
A. Facilitate the presence of friends and family whenever possible.
B. Teach the client about the harmful effects of anxiety on cardiac function.
C. Provide supplemental oxygen, as needed.
D. Provide validation of the client’s expressions of anxiety.
E. Administer benzodiazepines two to three times daily.

Answer 30

ANS: A, C, D
Rationale: The nurse should empathically validate the client’s sensations of anxiety. The
presence of friends and family is frequently beneficial, and oxygen supplementation
promotes comfort. Antianxiety medications may be necessary for some clients, but
alternative methods of relief should be prioritized. As well, medications are given on a
PRN basis. Teaching the client about the potential harms of anxiety is likely to
exacerbate, not relieve, the problem.

Question 31

A cardiovascular client with a previous history of pulmonary embolism (PE) is
experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse
recognizes the characteristic signs and symptoms of a PE. Which action is the nurse’s
best action?
A. Rapidly assess the client’s cardiopulmonary status.
B. Arrange for an electrocardiogram (ECG).
C. Increase the height of the client’s bed.
D. Manage the client’s anxiety.

Answer 31

ANS: A
Rationale: Client management in the event of a PE begins with cardiopulmonary
assessment and intervention. This is a priority over ECG monitoring, management of
anxiety, or repositioning of the client, even though each of these actions may be
appropriate and necessary.

Question 32

A cardiac client’s resistance to left ventricular filling has caused blood to back up into
the client’s circulatory system. Which health problem is likely to result?
A. Acute pulmonary edema
B. Right-sided heart failure
C. Right ventricular hypertrophy
D. Left-sided heart failure

Answer 32

ANS: A
Rationale: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The client quickly develops pulmonary edema from the blood
volume overload in the lungs. When the blood backs up into the pulmonary circulation,
right-sided heart failure, left-sided heart failure, and right ventricular hypertrophy do not
directly occur.

Question 33

A client who is at high risk for developing intracardiac thrombi has been placed on
long-term anticoagulation. Which aspect of the client’s health history creates a
heightened risk of intracardiac thrombi?
A. Atrial fibrillation
B. Infective endocarditis
C. Recurrent pneumonia
D. Recent surgery

Answer 33

ANS: A
Rationale: Intracardiac thrombi are especially common in clients with atrial fibrillation,
because the atria do not contract forcefully and blood flows slowly and turbulently,
increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent
surgery do not normally cause an increased risk for intracardiac thrombi formation.

Question 34

Diagnostic imaging reveals that the quantity of fluid in a client’s pericardial sac is
dangerously increased. The nurse should collaborate with the other members of the care
team to prevent the development of which complication?
A. Pulmonary edema
B. Pericardiocentesis
C. Cardiac tamponade
D. Pericarditis

Answer 34

ANS: C
Rationale: An increase in pericardial fluid raises the pressure within the pericardial sac
and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is
the treatment for this complication. Pericarditis and pulmonary edema do not result from
this pathophysiologic process

Question 35

The nurse is caring for a client with severe left ventricular dysfunction who has been
identified as being at risk for sudden cardiac death. Which medical intervention can be
performed that may extend the survival of the client?
A. Insertion of an implantable cardioverter defibrillator (ICD)
B. Insertion of an implantable pacemaker
C. Administration of a calcium channel blocker
D. Administration of a beta-blocker

Answer 35

ANS: A
Rationale: In clients with severe left ventricular dysfunction and the possibility of
life-threatening dysrhythmias, placement of an ICD can prevent sudden cardiac death
and extend survival. A pacemaker, a calcium channel blocker, and a beta-blocker are
not medical interventions that may extend the survival of the client with left ventricular
dysfunction.

Question 36

The nurse is caring for an adult client with heart failure who is prescribed digoxin.
When assessing the client for adverse effects, the nurse should assess for which of the
following signs and symptoms? Select all that apply.
A. Confusion
B. Shortness of breath
C. Numbness and tingling in the extremities
D. Chest pain
E. Bradycardia
F. Diuresis

Answer 36

ANS: A, E
Rationale: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms
include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other
listed signs and symptoms are not characteristic of digitalis toxicity.

Question 37

The nurse is addressing exercise and physical activity during discharge education
with a client diagnosed with heart failure. What should the nurse teach this client about
exercise?
A. “Do not exercise unsupervised.”
B. “Eventually aim to work up to 30 minutes of exercise each day.”
C. “Keep exercising but slow down if you get dizzy or short of breath.”
D. “Start your exercise program with high-impact activities.”

Answer 37

ANS: B
Rationale: Eventually, a total of 30 minutes of physical activity every day should be
encouraged. Supervision is not necessarily required and the emergence of symptoms,
such as dizziness or shortness of breath, should prompt the client to stop exercising, not
simply to slow the pace. Low-impact activities should be prioritized.