Chapter 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 36-year-old woman with aortic stenosis
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?
“I must stop halfway up the stairs to catch my breath.”
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?
“My shoes fit really tight lately.”
While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?
Assess for symptoms of left-sided heart failure.
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?
“Weight is the best indication that you are gaining or losing fluid.”
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?
“Avoid using salt substitutes.”
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?
Instruct the client to ask for assistance when rising from bed.
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?
Administer PRN acetaminophen.
A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client’s teaching?
“Do not take this medication within 1 hour of taking an antacid.”
A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client’s discharge teaching?
“Weigh yourself daily while wearing the same amount of clothing.”
A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
Assess the client’s respiratory status.
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?
Dyspnea on exertion
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?
“Blood clots form more easily in artificial replacement valves.”
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?
“I will have my teeth cleaned by my dentist in 2 weeks.”
A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use?
Standard Precautions
A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?
Friction rub at the left lower sternal border
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?
“Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes.”
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?
“Avoid large crowds and people who are sick.”
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?
“Would you like information about advance directives?”
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?
“Are you able to walk upstairs without fatigue?”
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?
“Would you like to talk more about this?”
A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client’s teaching?
“Gather everything you need for a chore before you begin.”
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?
Sit the client up with a pillow to lean forward on.
A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?
Atrial fibrillation
