Heart Failure Test Questions With All Correct Answers (Explained Answers)

Heart Failure Test Questions With All Correct Answers (Explained Answers) 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 EXPLANATION 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. 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 EXPLANATION 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. 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 EXPLANATION 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. 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 comes 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 EXPLANATION 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. 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 EXPLANATION Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Leftsided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure. The nurse notes that the client's 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 pulses alternant. - ANS: B EXPLANATION The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left. The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's 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 EXPLANATION 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. A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're 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 EXPLANATION Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? a. Place the client in a high Fowler's position. b. Begin cardiopulmonary resuscitation (CPR). c. Promote rest and minimize activities. d. Administer loop diuretics as prescribed. - ANS: D EXPLANATION 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 Fowler's 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. A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? a. Place the client in a high Fowler's position. b. Perform nasotracheal suctioning of the client. c. Auscultate the client's heart and lung sounds. d. Place the client on a 1000 mL fluid restriction. - ANS: A EXPLANATION placing a client in a high Fowler's position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client's heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed.