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Heart Failure

100

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? A. Apical pulse rate of 110 and 4+ pitting edema of feet. B. Thick white sputum and crackles that clear with cough. C. The client sleeping with no pillow and eupnea. D. Radial pulse rate of 90 and capillary refill time < 3 seconds.

A: Apical pulse rate of 110 and 4+ pitting edema of feet. Rationale:The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status.

200

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of “decreased cardiac output related to inability of the heart to pump effectively” is written. Which short-term goal would be best for the client? The client will: A. Be able to ambulate in the hall by date of discharge. B. Have an audible S1 and S2 with no S3 heard by end of shift. C. Turn, cough, and deep breathe every two (2) hours. D. Have a pulse oximeter reading of 98% by day two (2) of care.

B. Have an audible S1 and S2 with no S3 heard by end of shift Rationale: Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life threatening.

300

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? A. The client’s peripheral pitting edema has gone from 3+ to 4+. B. The client is able to take the radial pulse accurately. C. The client is able to perform ADLs without dyspnea. D. The client has minimal jugular vein distention.

C. the client is able to perform ADLs without dyspnea. Rationale:Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client’s condition is improving. The client’s heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.

400

The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? A. An elevated B-type natriuretic peptide (BNP). B. An elevated creatine kinase (CK-MB). C. A positive D-dimer. D. A positive ventilation/perfusion (V/Q) scan.

A: an elevated B-type natriuretic peptide (BNP) Rationale:BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF

500

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? A. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. B. Monitor the client’s potassium level and assess the client’s intake of bananas and orange juice. C. Determine if the client has gained weight and instruct the client to keep the legs elevated. D. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

B.Monitor the client’s potassium level and assess the client’s intake of bananas and orange juice. RationaleThe most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium.

Stable Angina

100

While the nurse is ambulating the client diagnosed with angina to the bathroom, the client begins to complain of chest pain radiating to the left arm. Which intervention should the nurse implement first? A. Administer a nitroglycerin tablet sublingually. B. Return the client to bed and tell client to lie in the bed. C. Place oxygen on the client via nasal cannula. D. Request a stat electrocardiogram (ECG).

B. Return the client to bed and tell the client to lie in the bed, Rationale:The nurse should first have the client lie down to help decrease the need for oxygen to the myocardium. Then the nurse should administer sublingual nitroglycerin and place oxygen on the client. After these interventions, the nurse should request a stat ECG

200

Which statement indicates the client diagnosed with angina needs more discharge teaching? A. “I will keep my nitroglycerin in a dark bottle at all times.” B. “I should stay on a low-fat, low-cholesterol diet.” C. “I will not walk outside if it is colder than 40ºF.” D. “I should perform isometric exercises three times a week.”

D. "I should perform isometric exercises three times a week." Rationale:Isometric exercises are musclebuilding exercises such as weightlifting. The client should perform isotonic exercises such as walking and swimming. This indicates the client needs more discharge teaching. All other statements indicate the client understands the teaching

300

The client comes to the emergency department complaining of chest pain. Which comment by the client would indicate to the nurse the client is experiencing angina instead of a myocardial infarction? A. “I was resting in my recliner when my chest started hurting.” B. “I was mowing my lawn when I started having chest pain.” C. “I started having chest pain when I took a deep breath.” D. “My heart started pounding in my chest and then I felt pain.”

B. "I was mowing my lawn when I started having chest pain." Rationale:Angina is usually brought on by activity such as exercising, cold weather (constriction), stress, or sexual intercourse

400

The charge nurse is observing a licensed practical nurse (LPN) applying a nitroglycerin patch to the client diagnosed with angina. Which action warrants immediate intervention from the charge nurse? A. The LPN places the nitroglycerin patch on a non-hairy area. B. The LPN dates and times the nitroglycerin patch. C. The LPN wears gloves when applying the nitroglycerin patch. D. The LPN applies the new patch while leaving the old patch in place.

D: The LPN applies the new patch while leaving the old patch in place. Rationale:The LPN should remove the old patch prior to administering the new patch

500

The nurse is discussing modifiable risk factors with the client diagnosed with angina. Which instructions should be included in the instructions? Select all that apply. A. Discuss the importance of eating a diet low in fiber. B. Explain the need to keep the cholesterol level under 200 mg/dL. C. Instruct the client to walk for 30 minutes three times a week. D. Tell the client to decrease the amount of cigarettes smoked daily. E. Inform the client the blood glucose level should be 70–120 mg/dL.

B,C,E Rationale:Risk factors include a high cholesterol level, sedentary lifestyle, cigarette smoking, and diabetes. The client must quit smoking, not just decrease smoking. The client should eat a low-fat, lowcholesterol, and high-fiber diet

Pharmacology

100

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? A. Instruct the client to take a cough suppressant if a cough develops. B. Teach the client how to prevent orthostatic hypotension. C. Encourage the client to eat bananas to increase potassium level. D. Explain the importance of taking the medication with food.

B. Teach the client how to prevent orthostatic hypotension. Rationale:Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored.

200

The nurse is transcribing the doctor’s orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement? A. Discuss the order with the health-care provider. B. Take the client’s apical pulse rate before administering. C. Check the client’s potassium level before giving the medication. D. Determine if a digoxin level has been drawn.

A. Discuss the order with the health care provider. Rationale:This dosage is 10 times the normal dose for a client with CHF. This dose is potentially lethal

300

Which data would cause the nurse to question administering digoxin to a client diagnosed with congestive heart failure? A. The potassium level is 3.2 mEq/L. B. The digoxin level is 1.2 mcg/mL. C. The client’s apical pulse is 64. D. The client denies yellow haze

A. The potassium level is 3.2 mEq/L RationaleThis potassium level is below normal levels; hypokalemia can potentiate digoxin toxicity and lead to cardiac dysrhythmias

400

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? A. The client has a BP of 110/70. B. The client has an apical pulse of 56. C. The client is complaining of a headache. D. The client’s potassium level is 4.5 mEq/L.

B. the client has an apical pulse of 56. Rationale:A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-thannormal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate.

500

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? A. Assess the client’s radial pulse. B. Assess the client’s serum potassium level. C. Assess the client’s glucometer reading. D. Assess the client’s pulse oximeter reading

B. Assess the client's serum potassium level. Rationale:Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client’s potassium level, and if the client is hypokalemic, the nurse should question administering this medication.

Misc

100

What is the priority problem in the client diagnosed with congestive heart failure? A. Fluid volume overload. B. Decreased cardiac output. C. Activity intolerance. D. Knowledge deficit.

B. Decreased cardiac output Rationsale:Decreased cardiac output is responsible for all the signs/symptoms associated with CHF and eventually causes death, which is why it is the priority problem.

200

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? A. Instruct the client to use a soft-bristle toothbrush. B. Discuss the importance of getting a monthly partial thromboplastin time (PTT). C. Teach the client about signs of pacemaker malfunction. D. Explain to the client the procedure for synchronized cardioversion.

A. Instruct the client to use a soft-bristle tooth brush. Rationale:A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush

300

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? A. “I will not eat more than six (6) eggs a week.” B. “I should bake or grill any meats I eat.” C. “I will drink eight (8) ounces of whole milk a day.” D. “I should not eat any type of pork products.”

B. "I should bake or grill any meats I eat." Rationale:The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat

400

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? A. Put a nitroglycerin tablet under the tongue. B. Stop the activity immediately and rest. C. Document when and what activity caused angina. D. Notify the health-care provider immediately

B: Stop the activity immediately and rest. Rationale:Stopping the activity decreases the heart’s need for oxygen and may help decrease the angina (chest pain).

500

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? A. “Do you have a daily bowel movement?” B. “Do you get yearly chest x-rays?” C. “Are you sexually active?” D. “Have you had any weight change?”

C. "Are you sexually active?" Rationale:Sexual activity is a risk factor for angina resulting from coronary artery disease. The client’s being elderly should not affect the nurse’s assessment of the client’s concerns about sexual activity

Delegation

100

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? A. Assist the client to go down to the smoking area for a cigarette. B. Transport the client to the intensive care unit via a stretcher. C. Provide the client going home discharge-teaching instructions. D. Help position the client who is having a portable x-ray done.

D. Help position the client who is having a portable x-ray RationaleThe UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment

200

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? A. The client diagnosed with congestive heart failure who is being discharged in the morning. B. The client who is having frequent incontinent liquid bowel movements and vomiting. C. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. D. The client who is complaining of chest pain with inspiration and a nonproductive cough.

C. The client with an apical pulse rate of 116, respiratory rate of 26 and a blood pressure of 94/62. Rationale:This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client.

300

The charge nurse is making assignments for clients on a medical unit. Which client should the charge nurse assign to the recent graduate nurse? A. The client diagnosed with angina whose pain is unrelieved with nitroglycerin. B. The client who is scheduled for a left-sided cardiac catheterization. C. The client with a myocardial infarction whose pulse oximeter reading is 90%. D. The client diagnosed with heart disease who needs discharge teaching

B. The client who is scheduled for a left-sided cardiac catheterization. Rationale: A newly graduated nurse would be able to care for a stable client scheduled for a cardiac catheterization. The client with angina not relieved by nitroglycerin is not stable, and a client with hypoxemia (a pulse oximeter reading less than 93%) should be assigned to a more experienced nurse, as should discharge teaching

400

The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first? A. Tell the UAP to go take the client’s vital signs. B. Ask the UAP to have the telemetry nurse read the strip. C. Notify the client’s health-care provider. D. Go to the room and assess the client’s chest pain.

D. Go to the room and assess the clients chest pain. Rationale:Assessment is the first step in the nursing process and should be implemented first; chest pain is priority.

500

The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor? A. The client admitted for diagnostic tests to rule out valvular heart disease. B. The client three (3) days post–myocardial infarction being discharged tomorrow. C. The client exhibiting supraventricular tachycardia (SVT) on telemetry. D. The client diagnosed with atrial fibrillation who has an INR of five (5).

B. The client three days post-myocardial infarction being discharged tomorrow Rationale:Because this client is being discharged, it would be an appropriate assignment for the new graduate