Cardiovascular 3 - Case study 15
The nurse admits Ms. C, an 81-year-old to the ICU. Ms. C, who has a history of mitral valve regurgitation
and left ventricular failure, came to the ED with symptoms of increasing shortness of breath over the
past week. The client received furosemide 100 mg IV in the ED, and she is receiving oxygen via nasal
cannula at 4L/min. When Ms. C arrives in the ICU, she is sitting up at a 60 degree angle. She is pale, with
circumoral cyanosis, and her respirations appear labored and rapid. She indicates that she feels very
short of breath.
What action should the nurse take first?
1. Listen to the breath sounds
2. Ask when the dyspnea started
3. Check to oxygen saturation
4. Raise the head of the bed to 75 degrees ANS: 3. Check to oxygen saturation
When the nurse assesses Ms. C, she has crackles audible throughout both lung fields and is coughing up
pink, frothy sputum. her oxygen saturation is 85% with the oxygen at 4L/min per the nasal cannula.
Respiratory rate is 38 breaths/min, and she has 3+ to 4+ pitting edema in her feet and up to her midcalf.
With the head of the bed elevated to a 75 degree angle, the jugular veins are distended up to the
jawline.
Based on the client's history and assessment, the nurse will be most concerned about which
complication?
1. Pulmonary edema
2. Cor pulmonale
3. Pneumonia
4. Pulmonary embolus ANS: 1. Pulmonary edema
What action will the nurse take next?
1. Activate the hospital's rapid response team (RRT)
, 2. Switch to a nonrebreather mask at a O2 flow rate of 15 L/min
3. Assist the client to cough and deep breathe
4. Administer the prescribed morphine sulfate 2 mg IV to the client ANS: 2. Switch to a nonrebreather
mask at a O2 flow rate of 15 L/min
What additional assessment data are most important to obtain at this time?
1. Skin color and capillary refill
2. Orientation and pupil reaction to light
3. Heart sounds and point of maximum impulse
4. Blood pressure and apical pulse ANS: 4. Blood pressure and apical pulse
Ms. C's blood pressure is 98/52 mm Hg, and her apical pulse is 116 beats/min. The cardiac monitor
shows sinus tachycardia at a rate of 110 to 120 beats/min. Which action prescribed by the health care
provider (HCP) will the nurse implement first?
1. Give Enalapril 2.5 mg PO
2. Administer furosemide 100 mg IV
3. Obtain a blood potassium level
4. Insert a no. 16 French Foley catheter ANS: 3. Obtain a blood potassium level
Which presrcibed action is best to assign to the experienced LPN who is assisting with the client's care?
1. Give Enalapril 2.5 mg PO
2. Administer furosemide 100 mg IV
3. Obtain a blood potassium level
4. Insert a no. 16 French Foley catheter ANS: 4. Insert a no. 16 French Foley catheter
The nurse administers morphine sulfate 2 mg IV to Ms. C. A new RN graduate who has just started in the
ICU ask why morphine is prescribed for this client. What is the best response?
The nurse admits Ms. C, an 81-year-old to the ICU. Ms. C, who has a history of mitral valve regurgitation
and left ventricular failure, came to the ED with symptoms of increasing shortness of breath over the
past week. The client received furosemide 100 mg IV in the ED, and she is receiving oxygen via nasal
cannula at 4L/min. When Ms. C arrives in the ICU, she is sitting up at a 60 degree angle. She is pale, with
circumoral cyanosis, and her respirations appear labored and rapid. She indicates that she feels very
short of breath.
What action should the nurse take first?
1. Listen to the breath sounds
2. Ask when the dyspnea started
3. Check to oxygen saturation
4. Raise the head of the bed to 75 degrees ANS: 3. Check to oxygen saturation
When the nurse assesses Ms. C, she has crackles audible throughout both lung fields and is coughing up
pink, frothy sputum. her oxygen saturation is 85% with the oxygen at 4L/min per the nasal cannula.
Respiratory rate is 38 breaths/min, and she has 3+ to 4+ pitting edema in her feet and up to her midcalf.
With the head of the bed elevated to a 75 degree angle, the jugular veins are distended up to the
jawline.
Based on the client's history and assessment, the nurse will be most concerned about which
complication?
1. Pulmonary edema
2. Cor pulmonale
3. Pneumonia
4. Pulmonary embolus ANS: 1. Pulmonary edema
What action will the nurse take next?
1. Activate the hospital's rapid response team (RRT)
, 2. Switch to a nonrebreather mask at a O2 flow rate of 15 L/min
3. Assist the client to cough and deep breathe
4. Administer the prescribed morphine sulfate 2 mg IV to the client ANS: 2. Switch to a nonrebreather
mask at a O2 flow rate of 15 L/min
What additional assessment data are most important to obtain at this time?
1. Skin color and capillary refill
2. Orientation and pupil reaction to light
3. Heart sounds and point of maximum impulse
4. Blood pressure and apical pulse ANS: 4. Blood pressure and apical pulse
Ms. C's blood pressure is 98/52 mm Hg, and her apical pulse is 116 beats/min. The cardiac monitor
shows sinus tachycardia at a rate of 110 to 120 beats/min. Which action prescribed by the health care
provider (HCP) will the nurse implement first?
1. Give Enalapril 2.5 mg PO
2. Administer furosemide 100 mg IV
3. Obtain a blood potassium level
4. Insert a no. 16 French Foley catheter ANS: 3. Obtain a blood potassium level
Which presrcibed action is best to assign to the experienced LPN who is assisting with the client's care?
1. Give Enalapril 2.5 mg PO
2. Administer furosemide 100 mg IV
3. Obtain a blood potassium level
4. Insert a no. 16 French Foley catheter ANS: 4. Insert a no. 16 French Foley catheter
The nurse administers morphine sulfate 2 mg IV to Ms. C. A new RN graduate who has just started in the
ICU ask why morphine is prescribed for this client. What is the best response?
