EDITION UPDATED 100% VERIFIED CORRECT
The nurse suspects a clients heart is failing when which of the following heart sounds is
assessed?
1. S1
2. S2
3. S3
4. S4
3. S3
An auscultated S3 is a sign that increased blood volume remains in the ventricle with each beat
and
that the heart is beginning to fail. S1 and S2 sounds are the first and second sounds heard when
ausculta ng the heart. An S4 sound may indicate increased resistance to ventricular filling.
A client is diagnosed with heart failure. Which of the following diagnos c tests is useful to
determine the degree of the failure?
1.Brain natriure c pep de level
2.Blood cultures
3.Sedimenta on rate
4.Arterial blood gas
1.Brain natriure c pep de level
Brain natriure c pep de is a hormone found in the le$ ventricle; it is used to help diagnose and
grade the severity of heart failure. Blood cultures are used to diagnose cardi s. Sedimenta on
rate is
used to diagnose pericardi s. Arterial blood gasses are not used to determine the degree of
heart
failure.
A nurse is instruc ng a client regarding medica ons and substances contraindicated for the
client
with heart failure. Which of the following would not be contraindicated?
1.Alcohol
2.Furosemide
, 3.Me(ormin
4.Pioglitazone
2. Furosemide
Loop diure cs (e.g., furosemide) are part of the recommended medica ons for heart failure.
Alcohol,
me(ormin, and pioglitazone (a thiazolidinedione) are contraindicated.
The nurse is determining nursing diagnoses appropriate for a client demonstra ng produc ve
cough with pink frothy sputum, shortness of breath, and crackles. Which of the following
nursing
diagnoses is of the most importance?
1.Ac vity intolerance
2.Anxiety
3. Impaired gas exchange
4. Risk for ineffec ve respiratory func on
3. Impaired gas exchange
The first priority is to maintain adequate oxygena on. The next diagnoses in priority would be
risk
for ineffec ve respiratory func on. Ac vity intolerance would be the third diagnosis. Anxiety
would
be the last diagnosis in order of priority.
In planning the care for a client diagnosed with heart failure, which of the following would be an
appropriate goal?
1.Reduce myocardial contrac lity.
2.Increase cardiac workload.
3.Decrease ejec on frac on.
4.Increase ac vity levels.
4.Increase ac vity levels.
An increase in ac vity levels would be an appropriate goal for the client diagnosed with heart
failure. The other op ons would be a decrease in ability, func on, or management of the heart
failure pa ent.
The nurse is instruc ng a client diagnosed with mild heart failure on dietary modifica ons.
Which