Ch. 35 Flashcards
A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?
a.
A 36-year-old woman with aortic stenosis
b.
A 42-year-old man with pulmonary hypertension
c.
A 59-year-old woman who smokes cigarettes daily
d.
A 70-year-old man who had a cerebral vascular accident
a.
A 36-year-old woman with aortic stenosis
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, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.
ref. 679
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?
a.
“I have been drinking more water than usual.”
b.
“I am awakened by the need to urinate at night.”
c.
“I must stop halfway up the stairs to catch my breath.”
d.
“I have experienced blurred vision on several occasions.”
c.
“I must stop halfway up the stairs to catch my breath.”
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.
ref. 682
A nurse assesses a client admitted to the cardiac unit. Which statement 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.
“My shoes fit really tight lately.”
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.
ref. 683
While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?
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.
Assess for symptoms of left-sided heart failure.
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.
ref. 683
A nurse cares for a client with right-sided heart failure. The client asks, “Why do I need to weigh myself every day?” How should the nurse respond?
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.
“Weight is the best indication that you are gaining or losing fluid.”
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. The other responses do not address the importance of monitoring fluid retention or loss.
ref. 683
A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client’s teaching?
a.
“Avoid using salt substitutes.”
b.
“Take your medication with food.”
c.
“Avoid using aspirin-containing products.”
d.
“Check your pulse daily.”
a.
“Avoid using salt substitutes.”
Angiotensin-converting enzyme (ACE) inhibitors such as enalapril 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. ACE inhibitors do not need to be taken with food and have no impact on the client’s pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.
ref. 685
After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client?
a.
Provide food to decrease nausea and aid in absorption.
b.
Instruct the client to ask for assistance when rising from bed.
c.
Collaborate with unlicensed assistive personnel to bathe the client.
d.
Monitor potassium levels and check for symptoms of hypokalemia.
b.
Instruct the client to ask for assistance when rising from bed.
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. ACE inhibitors do not need to be taken with food. Collaboration with unlicensed assistive personnel to provide hygiene is not a priority. The client should be encouraged to complete activities of daily living as independently as possible. The nurse should monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.
ref. 685
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?
a.
Initiate oxygen therapy.
b.
Hold the next dose of Imdur.
c.
Instruct the client to drink water.
d.
Administer PRN acetaminophen.
d.
Administer PRN acetaminophen.
The vasodilating effects of isosorbide mononitrate 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’s headache is not related to hypoxia or dehydration; therefore, these interventions would not help. The client needs to take the medication as prescribed to prevent angina; the medication should not be held.
ref. 686
A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client’s teaching?
a.
“Avoid taking aspirin or aspirin-containing products.”
b.
“Increase your intake of foods that are 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.
“Do not take this medication within 1 hour of taking an antacid.”
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 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy.
ref. 686
A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client’s discharge teaching?
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.
“Weigh yourself daily while wearing the same amount of clothing.”
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. Fluid overload increases symptoms of heart failure. The client should be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.
ref. 687
A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
a.
Assess the client’s respiratory status.
b.
Draw blood to assess the client’s serum electrolytes.
c.
Administer intravenous furosemide (Lasix).
d.
Ask the client about current medications.
a.
Assess the client’s respiratory status.
Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.
ref. 687
A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert 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
Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis.
ref. 688
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, “Why will I need to take anticoagulants for the rest of my life?” How should the nurse respond?
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.
“Blood clots form more easily in artificial replacement valves.”
Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.
ref. 696
After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client’s understanding. Which client statement indicates a need for additional teaching?
a.
“I’ll be able to carry heavy loads after 6 months of rest.”
b.
“I will have my teeth cleaned by my dentist in 2 weeks.”
c.
“I must avoid eating foods high in vitamin K, like spinach.”
d.
“I must use an electric razor instead of a straight razor to shave.”
b.
“I will have my teeth cleaned by my dentist in 2 weeks.”
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 a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy should be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.
ref. 694
A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use?
a.
Standard Precautions
b.
Bleeding precautions
c.
Reverse isolation
d.
Contact isolation
a.
Standard Precautions
The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions should be used. Bleeding precautions or reverse or contact isolation is not necessary.
ref. 697
