E2/H25 Flashcards
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
C. Pulmonary edema
pulmonary edema symptoms
restless, anxious, sudden onset of breathlessness, 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.
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.
D. The client’s age is greater than 65.
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.
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
C. Atherosclerosis
Atherosclerosis of the coronary arteries is the primary cause of heart failure.
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
B. Blood pressure
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.
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
B. Distended neck veins
right sided heart failure symptoms
distended neck veins (jugular veins), dependent edema, peripheral edema, hepatomegaly (right upper quadrant pain), weight gain, ascites, anorexia, nausea, nocturia, and weakness.
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
A. Stroke
Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke.
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
B. Potassium level
The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.
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?”
D. Gently shake and shout, “Are you OK?”
Assessing responsiveness is the first step in basic life support
Steps in basic life support
- Assessing responsiveness
- 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 ischecked by palpating the carotid artery.
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
B. Acute pulmonary edema
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.
Cardiogenic shock
signs of hypotension and tachycardia
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.
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
A. In a high Fowler position
help reduce venous return to the heart, lower the output of the right ventricle, or decrease lung congestion.
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).
D. Activate the Emergency Response System (ERS).
After checking for responsiveness and breathing, the nurse should activate the
ERS. Assessment of carotid pulse should follow and chest compressions may be
indicated.
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.
C. Monitor weight daily.
To assess fluid balance at home, the client should monitor daily weights at the
same time every day.
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
C. Bibasilar fine crackles
Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload.
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.”
B. “I will have a baked potato with broiled chicken for dinner.”
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
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.
B. Press the right upper abdomen.
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
B. The client admitted following an MI
Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic.
what is 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.
What is Pulsus Paradoxus
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.
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
D. A systolic blood pressure that is lower during inhalation
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
D. Asystole
when there is no heart rhythm at all (asystole)
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.
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.
D. Avoid positioning the client supine.
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.
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.
A. Improve functional status
C. Extend survival.
E. Relieve client symptoms.
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.
Endocarditis is not a common complication of heart failure and preventing it is not a major goal of care.
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
A. Blood pressure
Clients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function.
- 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)
A. A beta-adrenergic blocker
Several medications are routinely prescribed for systolic heart failure, including ACE inhibitors, beta-blockers, diuretics, and digitalis.
Medications prescribed for systolic heart failure
ACE inhibitors, beta-blockers, diuretics, and digitalis.
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
C. Combination of hydralazine and isosorbide dinitrate
A combination of hydralazine and isosorbide dinitrate may be an alternative for clients who cannot take ACE inhibitors.
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
A. Educating the client that symptom relief may not occur for several weeks
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.
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
A. An S3 heart sound
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.
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
D. Falls risk related to hypotension
The combination of low BP, diuretic use, and ACE inhibitor use constitutes a risk for falls.
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.
A. Perform at least 100 chest compressions per minute.
During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute.
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.
A. Know how to recognize and prevent orthostatic hypotension.
Clients with heart failure should be aware of the risks of orthostatic hypotension. Weight should be measured DAILY
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.
B. Take the diuretic in the morning to avoid interfering with sleep.
Discussing the timing of medication administration is especially important for older adult clients who may have urinary urgency or incontinence.
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.
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.
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.
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.
A. Rapidly assess the client’s cardiopulmonary status.
Client management in the event of a PE begins with cardiopulmonary assessment and intervention.
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
A. Acute pulmonary edema
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.
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
A. Atrial fibrillation
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.
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
C. Cardiac tamponade
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.
