Week 4 - HESI/EAQ Flashcards
the most common cause of heart failure is ________________
myocardial infarction
Heart failure results in the inability of the heart to provide sufficient blood flow to meet the _____________ of the body’s tissues and organs
oxygen needs
Heart failure occurs most commonly in clients over the age of ____, and occurs more commonly in _______________
Heart failure occurs most commonly in clients over the age of 60, and occurs more commonly in males than females.
Which assessment finding provides the earliest indication that the client is experiencing right-sided heart failure?
Dyspnea at rest.
Sinus tachycardia.
Peripheral edema.
Lack of energy.
Peripheral edema.
_________sided heart failure results in peripheral congestion due to the inability of the right ventricle to effectively pump blood out of the heart to the lungs, causing edema, JVD, an enlarged liver, abdominal ascites, and weight gain. Edema and weight gain are among the earlier signs.
Right-
After the client’s cardiac rhythm is confirmed, which action should the nurse implement next?
Administer a prescribed stat dose of digoxin.
Notify the HCP of the dysrhythmia.
Transfer the client to the Medical Intensive Care Unit (MICU).
Prepare for synchronized cardioversion.
Administer a prescribed stat dose of digoxin.
If a dose of digoxin has already been prescribed, it should be administered before taking further action. Digoxin slows the heart rate and increases the force of the heart’s contraction, which is very useful in the treatment of the client’s type of cardiac dysrhythmia.
Digoxin ______ the heart rate and increases the force of the heart’s contraction
slows
The client is scheduled for a chest x-ray, 12 lead electrocardiograph (ECG) and an echocardiogram.
When preparing the client for the echocardiogram, which intervention should the nurse implement?
Set-up treadmill for initial test.
Instruct the client to fast for at least 6 hours before the test.
Ensure the client is wearing comfortable clothes and shoes.
Ask the client to lay on their left side during the test.
Ask the client to lay on their left side during the test.
The echocardiogram records direction and flow of blood through the heart and transforms it to audio and graphic data that measure valve abnormalities, congenital heart defects, wall motion, ejection fraction (EF), and heart function. The best results are obtained when the patient is in a left side lying position.
Normal potassium is ______ mEq/L
3.5 - 5.0
The client is concerned about how easily they are bruising since they started taking the warfarin. Which intervention is most important for the nurse to include in the client’s plan of care?
Monitor INR levels every 4-6 weeks.
Use soft toothbrush to minimize bleeding gums.
Use electric razors for shaving.
Avoid contact sports and hobbies.
Monitor INR levels every 4-6 weeks.
The target INR for warfarin is 2.4 - 3.5. INR should be monitored on a regular basis. Changes in the warfarin dosage will be adjusted to keep the INR within a safe range which will decrease the risk of a life-threatening bleed.
[HF] The client asks the nurse why they have to be weighed every day. The nurse explains that weight gain is one of the first signs of retaining fluid. Which intervention is most important for the nurse to include in the client’s plan of care?
Weigh at the same time of day.
Keep a record of daily weights.
Report a gain of 3 pounds in one week.
Inform healthcare provider of ankle swelling.
Report a gain of 3 pounds in one week.
A weight gain of 3 pounds in 2 days or 3-5 pounds in a week should be reported immediately. This may indicate an exacerbation of the heart failure which requires immediate intervention.
Carvedilol works best if you take it with ______.
food
Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity?
Blood pressure 180/100.
Anorexia, nausea, and vomiting.
Pitting dependant ankle edema.
Blurred vision and halo vision.
Anorexia, nausea, and vomiting.
Gastrointestinal (GI) symptoms are among the earliest symptoms of digoxin toxicity, along with confusion and fatigue. Additional manifestations include headache, hypotension, and cardiac dysrhythmias.
A precipitous drop in serum ___________ may occur after treatment with digoxin immune FAB .
potassium
Respiratory ___________ is diagnosed with the PaCO2 is high and the pH is low.
acidosis
In an effort to monitor his heart failure, what is the most important intervention that the client can perform at home?
Check radial pulse 6 times a day, upon arising, at each meal, and before bed.
Take weekly ankle measurements to monitor edema.
Weighing every day on the same scale.
Incorporate a regular exercise routine.
Weighing every day on the same scale.
Daily weights are the most important intervention for monitoring heart failure. Clients should be instructed to call the HCP immediately with a weight gain of 2 to 3 lbs in 24 hours.
Which clinical manifestations further support a right-sided stroke? SATA
Visual field deficit on the left side.
Spatial-perceptual deficits.
Paresthesia of the left side.
Increased distractibility.
Global aphasia
Visual field deficit on the left side.
Spatial-perceptual deficits.
Paresthesia of the left side.
Increased distractibility.
The neurologist writes a diagnosis of “suspected stroke” and prescribes a computed tomography (CT) scan without contrast STAT. Which intervention should the nurse implement when preparing client and his son for this procedure?
Determine if the client has any allergies to iodine or shellfish.
Explain that the procedure requires the client to lie completely still.
Offer client an anxiolytic prior to the procedure.
Ensure that client does not have on any material that is metal, this includes metal prosthesis.
Explain that the procedure requires the client to lie completely still.
The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immediate intervention by the nurse concerning this diagnostic test?
Elevated heart rate.
Allergy to iodine.
Left hip replacement.
History of hypertension.
Left hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure.
With a diagnosis of a stroke, which priority interventions should the nurse include in client’s plan of care?
Monitor PTT daily.
Assess neurological status every hour.
Evaluate platelet levels daily.
Keep the head of the bed elevated.
Monitor blood glucose levels daily.
Monitor PTT daily.
Assess neurological status every hour.
Keep the head of the bed elevated.
Monitor blood glucose levels daily.
Homonymous hemianopsia is loss of the visual field blindness in the ______ ______ of each visual field.
same half
The student nurse rechecks the client’s blood pressure now that he has been sitting quietly for a few minutes. His blood pressure is 180/106 mmHg.
According to the assessment of this client, which recommendation is most important for the student nurse to provide?
See the HCP as soon as possible within the next week for a BP recheck.
Limit salt intake and start a weight loss program.
Attend a stress reduction seminar offered in his community.
Learn about high fiber foods and add more fiber to his diet.
See the HCP as soon as possible within the next week for a BP recheck.
The client’s blood pressure is significantly elevated. Since these BP readings were obtained on the same day, the client needs to see his HCP as soon as possible for another BP measurement. The HCP can then determine a diagnosis and initiate treatment.
Often clients with hypertension have no symptoms and ____________ may occur before the client becomes symptomatic.
organ damage
Most cases of hypertension are without an identified ______ and effected by multiple risk factors, so unless there is a health history indicator, the HCP does not look for one.
cause
Use of _________ products is linked with increased risk for cardiovascular disease.
tobacco
“Phantom limb pain is caused by the severing of _________ nerves.”
peripheral
The client tells the nurse that every time he walks a short distance, he gets an aching or cramping pain in his left leg.
How should the nurse correctly document this data?
Paresthesia.
Intermittent claudication.
Deep vein thrombosis (DVT).
Peripheral neuropathy.
Intermittent claudication.
A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment finding would alert the nurse to the possible development of thrombocytopenia? Select all that apply. One, some, or all responses may be correct.
Fever
Diarrhea
Melena
Hematuria
Ecchymosis
Nausea
Alopecia
Mucositis
Melena
Hematuria
Ecchymosis
The nurse reviews the medical record of a client with a grade 2 goiter. Which assessment finding is consistent with this type of goiter?
It is impalpable.
It is asymmetrical.
It moves up when the client swallows.
It is invisible when the client’s neck is in the normal position.
It is asymmetrical.
Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery?
Maintain muscle strength
Reduce leg discomfort
Prevent clot formation
Improve wound healing
Prevent clot formation
Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct.
Providing oxygen
Assessing vital signs
Obtaining a 12-lead EKG
Drawing blood for cardiac enzymes
Auscultating heart sounds
Administering nitroglycerin
All of the above
