ch 25 complications from heart disease

Question 1

dyspnea, productive mucoid cough, peripheral cyanosis, noisy moist sounding breathing. S/S of what

Answer 1

pulmonary edema

Question 2

which assessment finding indicates increase in clients risk for heart failure

Answer 2

clients age greater than 65

Question 3

which condition is a potential primary cause of heart failure

Answer 3

atherosclerosis

Question 4

priority assessment for loop diuretic treatment for heart failure

Answer 4

blood pressure

Question 5

which assessment finding is most consistent with right sided heart failure

Answer 5

distended neck veins

Question 6

for heart failure developed into intracardic thrombus, the nurse should assess for s/s of which sequela

Answer 6

stroke

Question 7

what assessment for digoxin toxicity

Answer 7

potassium level

Question 8

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

Answer 8

gently shake and shout are you ok

Question 9

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

Answer 9

acute pulmonary edema

Question 10

what position of client for pulmonary edema

Answer 10

in a high fowler position

Question 11

what is the appropriate response if a patient is unresponsive and not breathing

Answer 11

activate emergency response system

Question 12

nursing education for to assess fluid balance in the hope setting for patient with heart failure

Answer 12

monitor weight daily

Question 13

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

Answer 13

bibasilar fine crackles

Question 14

nurse education for low sodium diet

Answer 14

i will have baked potato with broiled chicken for dinner

Question 15

what action should a nurse perform during assessment of hepatojugular reflex

Answer 15

press the right upper abdomen (distention = right side heart failure)

Question 16

which client has greatest risk for developing cardio genic shock

Answer 16

patient admitted following MI

Question 17

pulsus paradoxus is characterized by what assessment finding

Answer 17

a systolic bp that is lower during inhalation

Question 18

when providing cpr documentation, how should the nurse describe the initial absence of cardiac rhythm

Answer 18

asystole

Question 19

what nursing action is most indicated for patient history of orthopnea

Answer 19

avoid positioning client supine

Question 20

what are overall goals when planning care of patient with heart failure

Answer 20

improve functional status
extend survival
relieve client symptoms

Question 21

when beginning treatment with angiotensin-converting enzyme (ACE) inhibitor, the nurse should prioritize which assessment

Answer 21

blood pressure

Question 22

what meds for systolic heart failure

Answer 22

beta adrenergic blocker

Question 23

which combination of drugs if adverse reaction to ACE inhibitors

Answer 23

hydralazine/isosorbide dinitrate

Question 24

priority during gradual increase of beta blocker dose

Answer 24

educating client that symptom relief may not occur for several weeks

Question 25

presence of which sound indicates heart failure

Answer 25

S3 heart sound

Question 26

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

Answer 26

fall risk due to hypotension

Question 27

when doing chest compression the nurse should do which of the following

Answer 27

perform at least 100 chest compressions per minute

Question 28

nursing education for oral diuretics

Answer 28

take diuretic in morning to avoid interfering with sleep

Question 29

what interventions for anxiety related to heart failure

Answer 29

-facilitate the presence of friends and family whenever possible -provide supplemental oxygen as needed -provide validation for client’s expression of anxiety

Question 30

what is the best action when recognize s/s of pulmonary embolism

Answer 30

rapidly assess clients cardiopulmonary status

Question 31

patients resistance to left ventricular filling has caused blood to backup into the client’s circulatory system. which health problem is likely to occur

Answer 31

acute pulmonary edema

Question 32

which aspect of patient health history creates a heightened risk for intacardiac thrombi

Answer 32

atrial fibrillation

Question 33

imaging shows quantity of fluid in patients pericardial sac is dangerously increased. priority to prevent which complication

Answer 33

cardiac tamponade

Question 34

patient with severe left ventricular dysfunction is at risk for sudden cardiac death. which medical intervention extends survival

Answer 34

insertion of implantable cardioverter defribrilator (ICD)

Question 35

adverse effects of digoxin

Answer 35

confusion, bradycardia

Question 36

nursing education for exercise related to heart failure

Answer 36

eventually aim to work up to 30 minutes a day

Question 37

which is most important to add to at home checklist for discharged patient with heart failure

Answer 37

know how to recognize and prevent orthostatic hypotension