Chapter 37: Care of Patients with Cardiac Problems Nursing School Test Banks

Chapter 37: Care of Patients with Cardiac Problems

Test Bank

MULTIPLE CHOICE

1. A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect?

a.

A decrease in blood pressure and urine output

b.

An increase in creatinine and extremity edema

c.

An increase in heart rate and respiratory rate

d.

A decrease in respirations and oxygen saturation

ANS: C

In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 746

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change?

a.

Increase in stroke volume

b.

Decrease in tissue perfusion

c.

Increase in oxygen saturation

d.

Decrease in arterial vasoconstriction

ANS: B

In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. Stroke volume and oxygen saturation do not increase with a low ejection fraction.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure?

a.

Middle-aged woman with aortic stenosis

b.

Middle-aged man with pulmonary hypertension

c.

Older woman who smokes cigarettes daily

d.

Older man who has had a myocardial infarction

ANS: A

Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure?

a.

I have been drinking more water than usual.

b.

I have been awakened by the need to urinate at night.

c.

I have to stop halfway up the stairs to catch my breath.

d.

I have experienced blurred vision on several occasions.

ANS: C

Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or catching their breath. This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 748

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

5. A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client?

a.

Please come into the clinic for an evaluation.

b.

Increase your fluid intake during waking hours.

c.

Use an over-the-counter cough suppressant.

d.

Sleep on two pillows to facilitate postnasal drainage.

ANS: A

The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure?

a.

I sleep with four pillows at night.

b.

My shoes fit really tight lately.

c.

I wake up coughing every night.

d.

I have trouble catching my breath.

ANS: B

Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 748

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation)

MSC: Integrated Process: Nursing Process (Assessment)

7. The nurse notes that the clients apical pulse is displaced to the left. What conclusion can be drawn from this assessment?

a.

This is a normal finding.

b.

The heart is hypertrophied.

c.

The left ventricle is contracted.

d.

The client has pulsus alternans.

ANS: B

The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

8. The nurse assesses a client and notes the presence of an S3 gallop. What is the nurses best intervention?

a.

Assess for symptoms of left-sided heart failure.

b.

Document this as a normal finding.

c.

Call the health care provider immediately.

d.

Transfer the client to the intensive care unit.

ANS: A

The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

9. A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurses best response?

a.

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

b.

Daily weights will help us make sure that youre eating properly.

c.

The hospital requires that all inpatients be weighed daily.

d.

You need to lose weight to decrease the incidence of heart failure.

ANS: A

Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 749

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

10. A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurses best action?

a.

Place the client in a high Fowlers position.

b.

Begin cardiopulmonary resuscitation (CPR).

c.

Promote rest and minimize activities.

d.

Administer loop diuretics as prescribed.

ANS: D

The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowlers position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

11. A client with heart failure is experiencing acute shortness of breath. What is the nurses priority action?

a.

Place the client in a high Fowlers position.

b.

Perform nasotracheal suctioning of the client.

c.

Auscultate the clients heart and lung sounds.

d.

Place the client on a 1000 mL fluid restriction.

ANS: A

Placing a client in a high Fowlers position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the clients heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

12. A client with heart failure is prescribed enalapril (Vasotec). What is the nurses priority teaching for this client?

a.

Avoid using salt substitutes.

b.

Take your medication with food.

c.

Avoid using aspirin-containing products.

d.

Check your pulse daily.

ANS: A

Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Planning)

13. The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client?

a.

Administer this medication before meals to aid absorption.

b.

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

c.

Give the medication with milk to prevent stomach upset.

d.

Monitor the potassium level and check for symptoms of hypokalemia.

ANS: B

Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

14. The client who just started taking isosorbide dinitrate (Imdur) reports a headache. What is the nurses best action?

a.

Titrate oxygen to relieve headache.

b.

Hold the next dose of Imdur.

c.

Instruct the client to drink water.

d.

Administer PRN acetaminophen.

ANS: D

The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

15. The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention?

a.

Insert an indwelling urinary catheter.

b.

Monitor the clients blood pressure.

c.

Place the nitroglycerin under the clients tongue.

d.

Monitor the clients serum glucose level.

ANS: B

Intravenous nitroglycerin and morphine will decrease the clients blood pressure, so it is important to monitor closely for hypotension. Intravenous medications are not administered under the tongue. Although the client may need an indwelling urinary catheter to monitor output, it is not the priority. The clients glucose levels should not be affected by these medications.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

16. The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client?

a.

Avoid taking aspirin or aspirin-containing products.

b.

Increase your intake of foods high in potassium.

c.

Hold this medication if your pulse rate is below 80 beats/min.

d.

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

ANS: D

Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

17. A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse?

a.

Cough

b.

Headache

c.

Pulse of 62 beats/min

d.

Potassium of 2.9 mEq/L

ANS: D

Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headache may occur with any medication and is not a serious side effect. Bradycardia is not likely to occur with this medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Analysis)

18. The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the clients activity?

a.

Decrease in oxygen saturation from 98% to 95%

b.

Respiratory rate change from 22 to 28 breaths/min

c.

Systolic blood pressure change from 136 to 96 mm Hg

d.

Increase in heart rate from 86 to 100 beats/min

ANS: C

A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Evaluation)

19. The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication?

a.

Confusion

b.

Dysphagia

c.

Sacral edema

d.

Irregular heart rate

ANS: A

Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. Dysphagia, sacral edema, and an irregular heart rate are not related to pulmonary edema.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

20. A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure?

a.

Avoid drinking more than 3 quarts of liquids each day.

b.

Eat six small meals daily instead of three larger meals.

c.

When you feel short of breath, take an additional diuretic.

d.

Weigh yourself daily while wearing the same amount of clothing.

ANS: D

Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

21. A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurses priority intervention?

a.

Assess respiratory status.

b.

Monitor electrolyte levels.

c.

Administer intravenous fluids.

d.

Insert a Foley catheter.

ANS: A

Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

22. The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the clients stenosis has progressed?

a.

Oxygen saturation of 92%

b.

Dyspnea on exertion

c.

Muted systolic murmur

d.

Upper extremity weakness

ANS: B

Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

23. The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client?

a.

Bounding arterial pulse

b.

Slow, faint arterial pulse

c.

Narrowed pulse pressure

d.

Elevated systolic pressure

ANS: C

In aortic stenosis, the client presents with narrowed pulse pressure when blood pressure (BP) is assessed.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 760

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

24. A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurses best response?

a.

The prosthetic valve places you at greater risk for a heart attack.

b.

Blood clots form more easily in artificial replacement valves.

c.

The vein taken from your leg reduces circulation in the leg.

d.

The surgery left a lot of small clots in your heart and lungs.

ANS: B

Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

25. The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education?

a.

I will be able to carry heavy loads after 6 months of rest.

b.

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

c.

I will avoid eating foods high in vitamin K, like spinach.

d.

I will use an electric razor instead of a straight razor to shave.

ANS: B

Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Evaluation)

26. The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about?

a.

Family history of coronary artery disease

b.

Recent travel to Third World countries

c.

Pet ownership, especially cats with litter boxes

d.

History of a systemic infection within the past month

ANS: D

The clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. Assessing for coronary artery disease, recent travel, or pet ownership is not related to endocarditis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

27. The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use?

a.

Standard Precautions

b.

Bleeding Precautions

c.

Reverse isolation

d.

Contact isolation

ANS: A

The client with infective endocarditis does not pose any specific threat of transmitting the causative organism.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

28. A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client?

a.

Heart rate that speeds up and slows down

b.

Friction rub at the left lower sternal border

c.

Presence of a regularly gallop rhythm

d.

Coarse crackles in bilateral lung bases

ANS: B

The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not related.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 765

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

29. The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include?

a.

Take your digoxin at the same time every day.

b.

You should begin an aerobic exercise program.

c.

You should report episodes of dizziness or fainting.

d.

You may have only two alcoholic drinks daily.

ANS: C

The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

30. The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority?

a.

Rapid position changes can create shear and friction forces, which can tear out internal vascular sutures.

b.

The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure.

c.

The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes.

d.

The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.

ANS: C

Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 769

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

31. A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the clients discharge instructions?

a.

Use a soft-bristled toothbrush and avoid flossing.

b.

Avoid large crowds and people who are sick.

c.

Change positions slowly to avoid hypotension.

d.

Check your heart rate before taking the medication.

ANS: B

These agents cause immune suppression, leaving the client more vulnerable to infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Implementation)

32. A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, I know a transplant is my last chance, but I dont want to become a vegetable. What is the nurses best response?

a.

Would you like to speak with a priest or chaplain?

b.

I will consult a psychiatrist to speak with you.

c.

Do you want to come off the transplant list?

d.

Would you like information about advance directives?

ANS: D

The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

MSC: Integrated Process: Nursing Process (Implementation)

33. The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the clients activity level?

a.

Do you have trouble breathing or chest pain?

b.

Are you able to walk upstairs without fatigue?

c.

Do you awake with breathlessness during the night?

d.

Do you have new-onset heaviness in your legs?

ANS: B

Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the clients activity is the same or worse, or whether the client identifies a decrease in activity level.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Evaluation)

34. An older adult client with heart failure states, I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. What is the nurses best response?

a.

Would you like to talk about this more?

b.

Youre lucky to have such a devoted daughter.

c.

You must feel as though you are a burden.

d.

Would you like an antidepressant medication?

ANS: A

Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychological Integrity (Therapeutic Communication)

MSC: Integrated Process: Caring

35. An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority?

a.

Echocardiography

b.

Chest x-ray

c.

T4 and thyroid-stimulating hormone (TSH)

d.

Arterial blood gas

ANS: A

Echocardiography is considered the best tool for the diagnosis of heart failure. A chest x-ray probably will be done, and if the client has dyspnea, an arterial blood gas will be drawn, but the echocardiogram is the priority. T4 and TSH might be ordered to assess for a contributing cause of heart failure.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

36. The nurse is caring for a client with severe heart failure. What is the best position in which to place this client?

a.

High Fowlers, pillows under arms

b.

Semi-Fowlers, with legs elevated

c.

High Fowlers, with legs elevated

d.

Semi-Fowlers, on the left side

ANS: A

Placing the client in high Fowlers position, with pillows under the arms, allows for maximum chest expansion.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation)

37. The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction?

a.

Walk until you become short of breath and then walk back home.

b.

Gather everything you need for a chore before you begin.

c.

Pull rather than push or carry items heavier than 5 pounds.

d.

Take a walk after dinner every day to build up your strength.

ANS: B

Gathering all supplies needed for a chore at one time decreases the amount of energy needed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

38. A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurses best action?

a.

Administer the Vasotec.

b.

Recheck the blood pressure.

c.

Hold the Vasotec.

d.

Notify the health care provider.

ANS: A

The nurse should administer the medication. Generally, the health care provider will maintain the clients blood pressure between 90 and 110 mm Hg.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Planning)

39. A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication?

a.

Insert a separate IV access.

b.

Prepare a test bolus dose.

c.

Prepare the piggyback line.

d.

Administer furosemide (Lasix) first.

ANS: A

Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin. A test bolus is not needed, nor is Lasix. Because the medication should be given through a separate IV, it is not necessary to prepare a piggyback line.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE

1. The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.)

a.

Pulmonary crackles

b.

Confusion, restlessness

c.

Pulmonary hypertension

d.

Dependent edema

e.

S3/S4 summation gallop

f.

Cough worsens at night

ANS: A, B, E, F

Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle.

DIF: Cognitive Level: Knowledge/Remembering REF: Chart 37-1, p. 749

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply.)

a.

Hematocrit (Hct), 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

ANS: A, B, E, F

The hematocrit is low (should be 42.6%), indicating a dilutional ratio of red blood cells (RBCs) to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Evaluation)

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