Galen College of Nursing-Louisville NUR 170
Med Surg Lewis Ch 38
Heart Failure Exam
Questions Verified and
Provided with A+ Graded
Answers
, While assessing an older adult patient, the nurse notes jugular venous distention (JVD)
with the head of the patient's bed elevated 45 degrees. What does this finding indicate?
a.Jugular vein atherosclerosis
b. Incompetent jugular vein valves
c. Increased ventricular filling pressure
d. Decreased intravascular fluid volume
c. increased ventricular filling pressure
The jugular veins empty into the superior vena cava and then into the right atrium and
ventricle, so JVD with the patient sitting at a 45-degree angle reflects increased atrial
and ventricular 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 and morphine for the
treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which
clinical finding is the best indicator that the treatment has been effective?
a.Weight loss of 2 lb in 24 hours
b. Hourly urine output greater than 60 mL
c. Reduced dyspnea with the head of bed at 30 degrees
d. Patient denies experiencing chest pain or chest pressure
c. Reduced dyspnea with the head of bed at 30 degrees
Because the patient's 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
may also indicate that diuresis or improvement in cardiac output has occurred but are not
specific to evaluating this patient's response.
Med Surg Lewis Ch 38
Heart Failure Exam
Questions Verified and
Provided with A+ Graded
Answers
, While assessing an older adult patient, the nurse notes jugular venous distention (JVD)
with the head of the patient's bed elevated 45 degrees. What does this finding indicate?
a.Jugular vein atherosclerosis
b. Incompetent jugular vein valves
c. Increased ventricular filling pressure
d. Decreased intravascular fluid volume
c. increased ventricular filling pressure
The jugular veins empty into the superior vena cava and then into the right atrium and
ventricle, so JVD with the patient sitting at a 45-degree angle reflects increased atrial
and ventricular 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 and morphine for the
treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which
clinical finding is the best indicator that the treatment has been effective?
a.Weight loss of 2 lb in 24 hours
b. Hourly urine output greater than 60 mL
c. Reduced dyspnea with the head of bed at 30 degrees
d. Patient denies experiencing chest pain or chest pressure
c. Reduced dyspnea with the head of bed at 30 degrees
Because the patient's 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
may also indicate that diuresis or improvement in cardiac output has occurred but are not
specific to evaluating this patient's response.
