ch 25 complications from heart disease Flashcards
dyspnea, productive mucoid cough, peripheral cyanosis, noisy moist sounding breathing. S/S of what
pulmonary edema
which assessment finding indicates increase in clients risk for heart failure
clients age greater than 65
which condition is a potential primary cause of heart failure
atherosclerosis
priority assessment for loop diuretic treatment for heart failure
blood pressure
which assessment finding is most consistent with right sided heart failure
distended neck veins
for heart failure developed into intracardic thrombus, the nurse should assess for s/s of which sequela
stroke
what assessment for digoxin toxicity
potassium level
a patient is diaphoretic, pale, and weak and reports severe chest pain and shortness of breath. when the patient collapses what should you do first
gently shake and shout are you ok
patient comes to ed reporting increased shortness of breath. has history of left sided heart failure. client is agitated and occasionally coughing pink foamy sputum. s/s of what health problem
acute pulmonary edema
what position of client for pulmonary edema
in a high fowler position
what is the appropriate response if a patient is unresponsive and not breathing
activate emergency response system
nursing education for to assess fluid balance in the hope setting for patient with heart failure
monitor weight daily
the nurse is caring for a patient who just returned from or after inguinal hernia repair. received large volume of IV fluids and has a history of coronary artery disease, increased risk of left side heart failure. S/S
bibasilar fine crackles
nurse education for low sodium diet
i will have baked potato with broiled chicken for dinner
what action should a nurse perform during assessment of hepatojugular reflex
press the right upper abdomen (distention = right side heart failure)
which client has greatest risk for developing cardio genic shock
patient admitted following MI
pulsus paradoxus is characterized by what assessment finding
a systolic bp that is lower during inhalation
when providing cpr documentation, how should the nurse describe the initial absence of cardiac rhythm
asystole
what nursing action is most indicated for patient history of orthopnea
avoid positioning client supine
what are overall goals when planning care of patient with heart failure
improve functional status
extend survival
relieve client symptoms
when beginning treatment with angiotensin-converting enzyme (ACE) inhibitor, the nurse should prioritize which assessment
blood pressure
what meds for systolic heart failure
beta adrenergic blocker
which combination of drugs if adverse reaction to ACE inhibitors
hydralazine/isosorbide dinitrate
priority during gradual increase of beta blocker dose
educating client that symptom relief may not occur for several weeks
presence of which sound indicates heart failure
S3 heart sound
patient with heart failure discharged with ace inhibitor and loop diuretic prescription. recent vital signs include ox sat 93%, 81 bpm, bp 94/59 what is the nursing concern
fall risk due to hypotension
when doing chest compression the nurse should do which of the following
perform at least 100 chest compressions per minute
nursing education for oral diuretics
take diuretic in morning to avoid interfering with sleep
what interventions for anxiety related to heart failure
-facilitate the presence of friends and family whenever possible
-provide supplemental oxygen as needed
-provide validation for client’s expression of anxiety
what is the best action when recognize s/s of pulmonary embolism
rapidly assess clients cardiopulmonary status
patients resistance to left ventricular filling has caused blood to backup into the client’s circulatory system. which health problem is likely to occur
acute pulmonary edema
which aspect of patient health history creates a heightened risk for intacardiac thrombi
atrial fibrillation
imaging shows quantity of fluid in patients pericardial sac is dangerously increased. priority to prevent which complication
cardiac tamponade
patient with severe left ventricular dysfunction is at risk for sudden cardiac death. which medical intervention extends survival
insertion of implantable cardioverter defribrilator (ICD)
adverse effects of digoxin
confusion, bradycardia
nursing education for exercise related to heart failure
eventually aim to work up to 30 minutes a day
which is most important to add to at home checklist for discharged patient with heart failure
know how to recognize and prevent orthostatic hypotension
