Ch 29 NCLEX

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient?

a) Vasculitis
b) Enlargement of joints
c) Potassium levels
d) Flexion contractures

c) Potassium levels

Explanation:
A key concern associated with digoxin therapy is digitalis toxicity. Clinical manifestations of toxicity include anorexia, nausea, visual disturbances, confusion, and bradycardia. The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.

The nurse recognizes which of the following lab tests is a key diagnostic indicator of heart failure?

a) Complete blood count (CBC)
b) Creatinine
c) Blood urea nitrogen (BUN)
d) Brain natriuretic peptide (BNP)

d) Brain natriuretic peptide (BNP)

Explanation:
The BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of HF. A BUN, creatinine, and CBC are included in the initial workup.

Which of the following describes difficulty breathing when a patient is lying flat?

a) Bradypnea
b) Paroxysmal nocturnal dyspnea (PND)
c) Orthopnea
d) Tachypnea

c) Orthopnea

Explanation:
Orthopnea occurs when the patient is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.

The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock?

a) Increased urinary output
b) Hyperactive bowel sounds
c) Restlessness and confusion
d) High blood pressure

c) Restlessness and confusion

Explanation:
Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).

A patient has been diagnosed with congestive heart failure. Which of the following is a cause of crackles heard in the bases of the lungs?

a) Pulmonary congestion
b) Pulmonary hypertension
c) Heart palpitations
d) Mitral valve stenosis

a) Pulmonary congestion

Explanation:
Crackles heard in the bases of the lungs are a sign of pulmonary congestion. Heart palpitations are caused by tachydysrhythmias. Crackles heard in the bases of the lungs are not signs of pulmonary hypertension and mitral valve stenosis.

A patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention?

a) Assess oxygen saturation level
b) Administer angiotensin-converting enzyme inhibitors
c) Administer angiotensin II receptor blockers
d) Administer diuretics

a) Assess oxygen saturation level

Explanation:
Assessment is priority to determine severity of the exacerbation. It is important to assess the oxygen saturation level of a heart failure patient, as below normal oxygen saturation level can be life-threatening. Treatment options vary according to the severity of the patient’s condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve patient symptoms and reduce the workload on the heart by reducing afterload and preload.

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A patient who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly develops complaints of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the patient for other signs and symptoms of which of the following problems?

a) Pulmonary embolism
b) Myocardial infarction
c) Pneumonia
d) Pulmonary edema

a) Pulmonary embolism

Explanation:
Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction where emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

A nurse is teaching patients newly diagnosed with coronary heart disease (CHD) about their disease process and risk factors for heart failure. Which of the following problems can cause left-sided heart failure (HF)?

a) Cystic fibrosis
b) Ineffective right ventricular contraction
c) Pulmonary embolus
d) Myocardial ischemia

d) Myocardial ischemia

Explanation:
Myocardial dysfunction and HF can be caused by a number of conditions including coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Atherosclerosis of the coronary arteries is a primary cause of HF, and coronary artery disease is found in the majority of patients with HF. Ischemia causes myocardial dysfunction because it deprives heart cells of oxygen and causes cellular damage. MI causes focal heart muscle necrosis, the death of myocardial cells, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Left sided heart failure is caused by myocardial ischemia. Ineffective right ventricular contraction, pulmonary embolus, and cystic fibrosis cause right-sided heart failure.

The nurse identifies which of the following symptoms as a characteristic of right-sided heart failure?

a) Cough
b) Jugular vein distention (JVD)
c) Pulmonary crackles
d) Dyspnea

b) Jugular vein distention (JVD)

Explanation:
JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.

To assess for peripheral edema, the nurse will examine which of the following areas of the body?

a) Under the sacrum
b) Lips, earlobes
c) Upper arms
d) Feet, ankles

d) Feet, ankles

Explanation:
When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.

A nurse taking care of a patient recently admitted to the ICU observes the patient coughing up large amounts of pink, frothy sputum. Auscultation of the lungs reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this patient is developing which of the following problems?

a) Acute exacerbation of chronic obstructive pulmonary disease
b) Decompensated heart failure with pulmonary edema
c) Bilateral pneumonia
d) Tuberculosis

b) Decompensated heart failure with pulmonary edema

Explanation:
Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated HF with pulmonary edema.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately?

a) Ability to sleep through the night
b) Weight loss
c) Persistent cough
d) Increased appetite

c) Persistent cough

Explanation:
Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite should be reported immediately. Weight gain should be reported immediately. Frequent urination, causing interruption of sleep, should be reported immediately.

The nurse assessing a patient with an exacerbation of heart failure identifies which of the following symptoms as a cerebrovascular manifestation of heart failure (HF)?

a) Tachycardia
b) Ascites
c) Nocturia
d) Dizziness

d) Dizziness

Explanation:
Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion causes dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.

A nurse is assessing a patient with congestive heart failure for jugular vein distension (JVD). Which of the following observations is important to report to the physician?

a) JVD is noted 3 cm above the sternal angle.
b) JVD is noted at the level of the sternal angle.
c) No JVD is present.
d) JVD is noted 1 cm above the sternal angle.

a) JVD is noted 3 cm above the sternal angle.

Explanation:
JVD is assessed with the patient sitting at a 45° angle. Jugular vein distention greater than 3 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?

a) Bumetanide (Bumex)
b) Chlorothiazide (Diuril)
c) Ethacrynic acid (Edecrin)
d) Spironolactone (Aldactone)

d) Spironolactone (Aldactone)

Explanation:
Aldactone is a potassium-sparing diuretic. A thiazide diuretic is Diuril. Bumex and Edecrin are loop diuretics.

The nurse identifies which of the following symptoms as a manifestation of right-sided heart failure (HF)?

a) Accumulation of blood in the lungs
b) Reduction in cardiac output
c) Congestion in the peripheral tissues
d) Reduction in forward flow

c) Congestion in the peripheral tissues

Explanation:
Right-sided HF, failure of the right ventricle, results in congestion in the peripheral tissues and the viscera and causes systemic venous congestion and a reduction in forward flow. Left-sided HF refers to failure of the left ventricle; it results in pulmonary congestion and causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues.

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating which of the following?

a) Paroxysmal nocturnal dyspnea
b) Hyperpnea
c) Dyspnea on exertion
d) Orthopnea

d) Orthopnea

Explanation:
Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position. Dyspnea on exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Which of the following is the hallmark of systolic heart failure?

a) Pulmonary congestion
b) Basilar crackles
c) Low ejection fraction (EF)
d) Limitation of activities of daily living (ADLs)

c) Low ejection fraction (EF)

Explanation:
A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the patient’s symptoms.

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

a) I
b) IV
c) III
d) II

b) IV

Explanation:
Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In Class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In Class II there is a slight limitation of ADLs. In Class III there is marked limitation on ADLs.

Which action will the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?

a) Titrate milrinone rate slowly before discontinuing
b) Teach patient about safe home use of the medication
c) Encourage patient to ambulate in room
d) Monitor blood pressure frequently

d) Monitor blood pressure frequently

Explanation:
Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to patients with severe HF, including patients who are waiting for a heart transplant. Because the drug causes vasodilation, the patient’s blood pressure is monitored prior to administration since if the patient is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and following infusions of milrinone.

The nurse understands that a patient with which cardiac arrhythmia is most at risk for developing heart failure?

a) First-degree heart block
b) Sinus tachycardia
c) Atrial fibrillation
d) Supraventricular tachycardia

c) Atrial fibrillation

Explanation:
Cardiac dysrhythmias such as atrial fibrillation may either cause or result from HF; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.

Which of the following medications is categorized as a loop diuretic?

a) Furosemide (Lasix)
b) Chlorothiazide (Diuril)
c) Chlorthalidone (Hygroton)
d) Spironolactone (Aldactone)

a) Furosemide (Lasix)

Explanation:
Lasix is commonly used in the treatment of cardiac failure. Loop diuretics inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Chlorothiazide is categorized as a thiazide diuretic. Chlorthalidone is categorized as a thiazide diuretic. Spironolactone is categorized as a potassium-sparing diuretic.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

a) Echocardiogram
b) Electrocardiogram (ECG)
c) Serum electrolytes
d) Blood urea nitrogen (BUN)

a) Echocardiogram

Explanation:
An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed in the initial workup.

Which of the following nursing interventions should a nurse perform when a patient with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta blockers?

a) Observe for symptoms of pulmonary edema.
b) Continue the drug and document in the patient’s chart.
c) Check for signs of toxicity.
d) Withhold the drug and inform the primary health care provider.

d) Withhold the drug and inform the primary health care provider.

Explanation:
Before administering beta blockers, the nurse should monitor the patient’s apical pulse. If the heart rate is less than 60 bpm, the nurse should withhold the drug and inform the primary health care provider.

A patient with congestive heart failure is admitted to the hospital with complaints of shortness of breath. How should the nurse position the patient in order to decrease preload?

a) Head of the bed elevated at 30 degrees and legs elevated on pillows
b) Supine with arms elevated on pillows above the level of the heart
c) Prone with legs elevated on pillows
d) Head of the bed elevated at 45 degrees and lower arms supported by pillows

d) Head of the bed elevated at 45 degrees and lower arms supported by pillows

Explanation:
Preload is the amount of blood presented to the ventricle just before systole. The patient is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the patient may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the patient’s weight on the shoulder muscles.