Chapter 35

Question 1

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?

Answer 1

A 36-year-old woman with aortic stenosis

Question 2

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

Answer 2

“I must stop halfway up the stairs to catch my breath.”

Question 3

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?

Answer 3

“My shoes fit really tight lately.”

Question 4

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?

Answer 4

Assess for symptoms of left-sided heart failure.

Question 5

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?

Answer 5

“Weight is the best indication that you are gaining or losing fluid.”

Question 6

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?

Answer 6

“Avoid using salt substitutes.”

Question 7

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?

Answer 7

Instruct the client to ask for assistance when rising from bed.

Question 8

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?

Answer 8

Administer PRN acetaminophen.

Question 9

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client’s teaching?

Answer 9

“Do not take this medication within 1 hour of taking an antacid.”

Question 10

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client’s discharge teaching?

Answer 10

“Weigh yourself daily while wearing the same amount of clothing.”

Question 11

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?

Answer 11

Assess the client’s respiratory status.

Question 12

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?

Answer 12

Dyspnea on exertion

Question 13

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?

Answer 13

“Blood clots form more easily in artificial replacement valves.”

Question 14

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?

Answer 14

“I will have my teeth cleaned by my dentist in 2 weeks.”

Question 15

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use?

Answer 15

Standard Precautions

Question 16

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?

Answer 16

Friction rub at the left lower sternal border

Question 17

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, “Why is this important?” How should the nurse respond?

Answer 17

“Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes.”

Question 18

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this client’s discharge teaching?

Answer 18

“Avoid large crowds and people who are sick.”

Question 19

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, “I know a transplant is my last chance, but I don’t want to become a vegetable.” How should the nurse respond?

Answer 19

“Would you like information about advance directives?”

Question 20

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client’s heart failure?

Answer 20

“Are you able to walk upstairs without fatigue?”

Question 21

A nurse cares for an older adult client with heart failure. The client states, “I don’t know what to do. I don’t want to be a burden to my daughter, but I can’t do it alone. Maybe I should die.” How should the nurse respond?

Answer 21

“Would you like to talk more about this?”

Question 22

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client’s teaching?

Answer 22

“Gather everything you need for a chore before you begin.”

Question 23

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement?

Answer 23

Sit the client up with a pillow to lean forward on.

Question 24

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?

Answer 24

Atrial fibrillation

Question 25

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.)

a. Pulmonary crackles
b. Confusion, restlessness
c. Pulmonary hypertension
d. Dependent edema
e. Cough that worsens at night

Answer 25

A,B,E

Question 26

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.)

a. Hematocrit: 32.8%
b. Serum sodium: 130 mEq/L
c. Serum potassium: 4.0 mEq/L
d. Serum creatinine: 1.0 mg/dL
e. Proteinuria
f. Microalbuminuria

Answer 26

A,B,E,F

Question 27

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.)

a. A 36-year-old woman with systemic lupus erythematosus (SLE)
b. A 42-year-old man recovering from coronary artery bypass graft surgery
c. A 59-year-old woman recovering from a hysterectomy
d. An 80-year-old man with a bacterial infection of the respiratory tract
e. An 88-year-old woman with a stage III sacral ulcer

Answer 27

A,B,D

Question 28

After teaching a client with congestive heart failure (CHF), the nurse assesses the client’s understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)

a. “I’ll read the nutritional labels on food items for salt content.”
b. “I will drink at least 3 liters of water each day.”
c. “Using salt in moderation will reduce the workload of my heart.”
d. “I will eat oatmeal for breakfast instead of ham and eggs.”
e. “Substituting fresh vegetables for canned ones will lower my salt intake.”

Answer 28

A,D,E

Question 29

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.)

a. “Reposition the client every 2 hours.”
b. “Teach the client to perform deep-breathing exercises.”
c. “Accurately record intake and output.”
d. “Use the same scale to weigh the client each morning.”
e. “Place the client on oxygen if the client becomes short of breath.”

Answer 29

A,C,D

Question 30

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.)

a. Teach the client about dietary restrictions.
b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor.
c. Encourage the client to take a baby aspirin each day.
d. Confirm that an echocardiogram has been completed.
e. Consult a social worker for additional resources.

Answer 30

A,B,D

Question 31

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client’s safety prior to discharging home? (Select all that apply.)

a. “Are your bedroom and bathroom on the first floor?”
b. “What social support do you have at home?”
c. “Will you be able to afford your oxygen therapy?”
d. “What spiritual beliefs may impact your recovery?”
e. “Are you able to accurately weigh yourself at home?”

Answer 31

A,B,E

Question 32

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.)

a. Shortness of breath
b. Abdominal bloating
c. New-onset bradycardia
d. Increased ejection fraction
e. Hypertension

Answer 32

A,B,C

Question 33

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.)

a. Weight gain
b. Night sweats
c. Cardiac murmur
d. Abdominal bloating
e. Osler’s nodes

Answer 33

B,C,E