326 Exam 1 Questions with Verified
Solutions
A client with a history of hypertension and left ventricular failure arrives for a scheduled
clinic appointment and tells the nurse, "My feet are killing me. These got too tight." The
nurse's best initial action would be to?
a. Weigh the client
b. Notify the physician
c. Take the client's pulse
d. Listen to the client's breath sounds - ANSWER-a. weigh the client.
Shoes that become too tight indicate pedal edema, which is a sign of fluid retention: 2.2
pounds is equal to 1 liter of fluid
When performing a physical assessment of a client with heart failure, the adaptation
that would be unexpected is?
a.Dependent edema
b.Progressive fatigue
c.Moist, clammy skin
d. Collapsed neck veins - ANSWER-d.Collapsed neck veins
With heart failure the veins distend, not collapse because of congestion of the CV
system
The nurse understands that heart failure can be best be described as?
a.A cardiac condition caused by inadequate circulating blood volume
b.An acute state in which the pulmonary circulation decreases
c.An inability of the heart to pump blood in proportion to metabolic needs
d.A chronic state in which the systolic pressure drops below 90 mm Hg - ANSWER-c.An
inability of the heart to pump blood in proportion to metabolic needs
As the heart fails, cardiac output decreases; eventually the decrease will reach a level
that prevents tissues from receiving adequate oxygen and nutrients
The nurse suggests that a client with right ventricular failure should:
a.Take a hot bath before bedtime
b.Avoid sleeping in an air conditioned room
c.Avoid emotionally stressful situations when possible
d.Exercise daily until the pulse rate exceeds 100 beats/minute - ANSWER-c.Avoid
emotionally stressful situations when possible
Stressful situations increase the body's oxygen demands
,While obtaining a health history the nurse would expect a 70 year old client admitted to
the hospital with Heart Failure to report?
a.Tingling in the hands and arms
b.Feeling of "bloated" after eating
c.Need to use three pillows at night to sleep
d.Swelling of the ankles more apparent in the morning than at night - ANSWER-c.Need
to use three pillows at night to sleep
HF causes a fluid volume excess that results in pulmonary edema and dyspnea in the
supine position
During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous
distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse
knows this finding indicates
a. decreased fluid volume.
b. jugular vein atherosclerosis.
c. elevated right atrial pressure.
d. incompetent jugular vein valves. - ANSWER-ANS: C
The jugular veins empty into the superior vena cava and then into the right atrium, so
JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure.
JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid
volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine
for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea.
When evaluating the patient response to the medications, the best indicator that the
treatment has been effective is
a. weight loss of 2 pounds overnight.
b. hourly urine output greater than 60 mL.
c. reduction in patient complaints of chest pain.
d. decreased dyspnea with the head of bed at 30 degrees. - ANSWER-ANS: D
Because the patients major clinical manifestation of ADHF is orthopnea (caused by the
presence of fluid in the alveoli), the best indicator that the medications are effective is a
decrease in dyspnea with the head of the bed at 30 degrees. The other assessment
data also may indicate that diuresis or improvement in cardiac output has occurred but
are not as specific to evaluating this patients response.
Which topic will the nurse plan to include in discharge teaching for a patient with systolic
heart failure and an ejection fraction of 38%?
a. Need to participate in an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Importance of making a yearly appointment with the primary care provider
d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors -
ANSWER-ANS: D
The core measures for the treatment of heart failure established by The Joint
Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE
inhibitor to decrease the progression of heart failure. Aerobic exercise may not be
, appropriate for a patient with this level of heart failure, salt substitutes are not usually
recommended because of the risk of hyperkalemia, and the patient will need to see the
primary care provider more frequently than annually.
Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary
edema. During the first hours of administration, the nurse will need to adjust the
nitroprusside rate if the patient develops
a. a dry, hacking cough.
b. any ventricular ectopy.
c. a systolic BP <90 mm Hg.
d. a heart rate <50 beats/minute. - ANSWER-ANS: C
Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe
hypotension. Coughing and bradycardia are not adverse effects of this medication.
Nitroprusside does not cause increased ventricular ectopy.
A patient in the intensive care unit with acute decompensated heart failure (ADHF)
complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these
medications have been ordered for the patient. The first action by the nurse will be to
a.
give IV diazepam (Valium) 2.5 mg.
b.
administer IV morphine sulfate 2 mg.
c.
increase nitroglycerin (Tridil) infusion by 5 mcg/min.
d.
increase dopamine (Intropin) infusion by 2 mcg/kg/min. - ANSWER-ANS: B
Morphine improves alveolar gas exchange, improves cardiac output by reducing
ventricular preload and afterload, decreases anxiety, and assists in reducing the
subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not
improve the cardiac output or gas exchange. Increasing the dopamine may improve
cardiac output, but it also will increase the heart rate and myocardial oxygen
consumption. Nitroglycerin will improve cardiac output and may be appropriate for this
patient, but it will not directly reduce anxiety and will not act as quickly as morphine to
decrease dyspnea.
After receiving change-of-shift report, which of these patients admitted with heart failure
should the nurse assess first?
a.
A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure (BP) of
100/56
b.
A patient who is cool and clammy, with new-onset confusion and restlessness
c.
A patient who had dizziness after receiving the first dose of captopril (Capoten)
d.
Solutions
A client with a history of hypertension and left ventricular failure arrives for a scheduled
clinic appointment and tells the nurse, "My feet are killing me. These got too tight." The
nurse's best initial action would be to?
a. Weigh the client
b. Notify the physician
c. Take the client's pulse
d. Listen to the client's breath sounds - ANSWER-a. weigh the client.
Shoes that become too tight indicate pedal edema, which is a sign of fluid retention: 2.2
pounds is equal to 1 liter of fluid
When performing a physical assessment of a client with heart failure, the adaptation
that would be unexpected is?
a.Dependent edema
b.Progressive fatigue
c.Moist, clammy skin
d. Collapsed neck veins - ANSWER-d.Collapsed neck veins
With heart failure the veins distend, not collapse because of congestion of the CV
system
The nurse understands that heart failure can be best be described as?
a.A cardiac condition caused by inadequate circulating blood volume
b.An acute state in which the pulmonary circulation decreases
c.An inability of the heart to pump blood in proportion to metabolic needs
d.A chronic state in which the systolic pressure drops below 90 mm Hg - ANSWER-c.An
inability of the heart to pump blood in proportion to metabolic needs
As the heart fails, cardiac output decreases; eventually the decrease will reach a level
that prevents tissues from receiving adequate oxygen and nutrients
The nurse suggests that a client with right ventricular failure should:
a.Take a hot bath before bedtime
b.Avoid sleeping in an air conditioned room
c.Avoid emotionally stressful situations when possible
d.Exercise daily until the pulse rate exceeds 100 beats/minute - ANSWER-c.Avoid
emotionally stressful situations when possible
Stressful situations increase the body's oxygen demands
,While obtaining a health history the nurse would expect a 70 year old client admitted to
the hospital with Heart Failure to report?
a.Tingling in the hands and arms
b.Feeling of "bloated" after eating
c.Need to use three pillows at night to sleep
d.Swelling of the ankles more apparent in the morning than at night - ANSWER-c.Need
to use three pillows at night to sleep
HF causes a fluid volume excess that results in pulmonary edema and dyspnea in the
supine position
During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous
distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse
knows this finding indicates
a. decreased fluid volume.
b. jugular vein atherosclerosis.
c. elevated right atrial pressure.
d. incompetent jugular vein valves. - ANSWER-ANS: C
The jugular veins empty into the superior vena cava and then into the right atrium, so
JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure.
JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid
volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine
for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea.
When evaluating the patient response to the medications, the best indicator that the
treatment has been effective is
a. weight loss of 2 pounds overnight.
b. hourly urine output greater than 60 mL.
c. reduction in patient complaints of chest pain.
d. decreased dyspnea with the head of bed at 30 degrees. - ANSWER-ANS: D
Because the patients major clinical manifestation of ADHF is orthopnea (caused by the
presence of fluid in the alveoli), the best indicator that the medications are effective is a
decrease in dyspnea with the head of the bed at 30 degrees. The other assessment
data also may indicate that diuresis or improvement in cardiac output has occurred but
are not as specific to evaluating this patients response.
Which topic will the nurse plan to include in discharge teaching for a patient with systolic
heart failure and an ejection fraction of 38%?
a. Need to participate in an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Importance of making a yearly appointment with the primary care provider
d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors -
ANSWER-ANS: D
The core measures for the treatment of heart failure established by The Joint
Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE
inhibitor to decrease the progression of heart failure. Aerobic exercise may not be
, appropriate for a patient with this level of heart failure, salt substitutes are not usually
recommended because of the risk of hyperkalemia, and the patient will need to see the
primary care provider more frequently than annually.
Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary
edema. During the first hours of administration, the nurse will need to adjust the
nitroprusside rate if the patient develops
a. a dry, hacking cough.
b. any ventricular ectopy.
c. a systolic BP <90 mm Hg.
d. a heart rate <50 beats/minute. - ANSWER-ANS: C
Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe
hypotension. Coughing and bradycardia are not adverse effects of this medication.
Nitroprusside does not cause increased ventricular ectopy.
A patient in the intensive care unit with acute decompensated heart failure (ADHF)
complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these
medications have been ordered for the patient. The first action by the nurse will be to
a.
give IV diazepam (Valium) 2.5 mg.
b.
administer IV morphine sulfate 2 mg.
c.
increase nitroglycerin (Tridil) infusion by 5 mcg/min.
d.
increase dopamine (Intropin) infusion by 2 mcg/kg/min. - ANSWER-ANS: B
Morphine improves alveolar gas exchange, improves cardiac output by reducing
ventricular preload and afterload, decreases anxiety, and assists in reducing the
subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not
improve the cardiac output or gas exchange. Increasing the dopamine may improve
cardiac output, but it also will increase the heart rate and myocardial oxygen
consumption. Nitroglycerin will improve cardiac output and may be appropriate for this
patient, but it will not directly reduce anxiety and will not act as quickly as morphine to
decrease dyspnea.
After receiving change-of-shift report, which of these patients admitted with heart failure
should the nurse assess first?
a.
A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure (BP) of
100/56
b.
A patient who is cool and clammy, with new-onset confusion and restlessness
c.
A patient who had dizziness after receiving the first dose of captopril (Capoten)
d.
