Chapter 25 - 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

C. Pulmonary edema

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 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 2

D. The client’s age is greater than 65

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 3

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 3

C. Atherosclerosis

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 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

B. Blood pressure

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

B. Distended neck veins

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

A. Stroke

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

B. Potassium level

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

D. Gently shake and shout, “Are you OK?”

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

B. Acute pulmonary edema

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

A. In a high Fowler position

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

Activate the Emergency Response System (ERS).

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

C. Monitor weight daily.

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

C. Bibasilar fine crackles

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

B. “I will have a baked potato with broiled chicken for dinner.”

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

B. Press the right upper abdomen.

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

B. The client admitted following an MI

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

D. A systolic blood pressure that is lower during inhalation

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

D. Asystole

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

D. Avoid positioning the client supine.

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

A. Improve functional status
C. Extend survival.
E. Relieve client symptoms

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

A. Blood pressure

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

A. A beta-adrenergic blocker

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

C. Combination of hydralazine and isosorbide dinitrate

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

A. Educating the client that symptom relief may not occur for several weeks

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

A. An S3 heart sound

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

D. Falls risk related to hypotension

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

A. Perform at least 100 chest compressions per minute.

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

A. Know how to recognize and prevent orthostatic hypotension

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

B. Take the diuretic in the morning to avoid interfering with sleep.

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

A. Facilitate the presence of friends and family whenever possible.
C. Provide supplemental oxygen, as needed.
D. Provide validation of the client’s expressions of anxiety.

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

A. Rapidly assess the client’s cardiopulmonary status

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

A. Acute pulmonary edema

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

A. Atrial fibrillation

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

C. Cardiac tamponade

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

A. Insertion of an implantable cardioverter defibrillator (ICD)

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

A. Confusion
E. Bradycardia

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

B. “Eventually aim to work up to 30 minutes of exercise each day.”

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.