Med or class of med
Prevents the conversion of angiotensin I to angiotensin II
What are ace inhibitors
This needs monitored for the client taking Furosemide
What is potassium
Crackles, SOB, fatigue
What is left sided heart failure
Risk for Falls
Alarm
Nonskid footwear
Close to nurses station
Lighting
The nurse is planning care for several clients. Which client should the nurse identify as being at greatest risk of developing heart failure?
A) A 69-year-old African American male with hypertension
B) A 50-year-old African American female who smokes
C) A 75-year-old Caucasian male who is overweight
D) A 52-year-old Caucasian female with asthma
Who is:
A) A 69-year-old African American male with
hypertension
Increases the renal excretion of water, sodium, chloride, magnesium, calcium, and potassium
What is Furosemide
Lab value most often used to assist with diagnosis of heart failure
What is BNP
Trigger release of renin, ADH, aldosterone, epinephrine, norepinephrine to start kidney compensation
What is:
Non-progressive or Compensatory stage
Impaired Gas Exchange
O2 sat
Oxygen
Positioning
lung sounds
The nurse is assessing a client being treated for heart failure (HF). Which physical findings would indicate that the client's condition is not improving? Select all that apply.
A) Urine output 160 ml over 8 hours
B) Pulse oximetry reading of 96%
C) Temperature of 98.6°F (37°C)
D) Wheezing of breath sounds in all lobes
E) Moderate amount of clear, thin mucus
What is:
A) Urine output 160 ml over 8 hours
D) Wheezing of breath sounds in all lobes
Reduce autonomic nervous system effects by blocking beta-1 adrenergic receptor sites in the heart
What are Beta Blockers
Produced in the liver, makes up about 60% of total protein in the blood, can be used to determine nutritional status
What is albumin
Pitting edema, weight gain, distended neck veins
What is right sided heart failure
Fluid Volume Excess
assess for edema
elevate extremities
weight
fluid restriction
salt restriction
When planning care for this client, which does the nurse understand about systolic heart failure?
A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system
B) Results when the heart cannot completely relax in diastole, disrupting normal filling
C) Decreases passive diastolic filling, increasing the importance of atrial contraction to preload
D) Results from decreased ventricular compliance caused by hypertrophic and cellular changes and impaired relaxation of the heart muscle
What is:
A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system
Increases myocardial contractility. Must have an apical pulse prior to administration
What is Digoxin
Carries oxygen to and removes CO2 from red blood cells. Also serves as a buffer to maintain acid-base balance
What is Hemoglobin
MAP Drops >20mmHg
Cool moist skin,
rapid, weak pulse
What is:
Progressive or Immediate Stage
Fluid Volume Deficit
IV replacement color or urine/spec. gravity
Labs Mucus membranes
safety (BP, etc)
Skin turgor
I & O
Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply.
A) Slight increase in pulse
B) Dry, warm skin
C) Increased urine output
D) Normal respirations
E) Slight decrease in blood pressure
What is:
A) Slight increase in pulse
E) Slight decrease in blood pressure
Vasodilator to lower BP and decrease how hard the heart has to work
What are:
Hydralazine
Nitrates
Evaluate respiratory function and provide a measure for determining acid-base balance
What are:
ABG's
Rapid LOC, nonpalpable pulse,
Cold, dusky extremities
What is Refractory or Irreversible stage
Impaired Physical Mobility
Safety
Reposition
Assess skin
Rest periods
ROM
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
A. Hypotension
B. Narrowing pulse pressure
C. Anuria
D. Decreased level of consciousness (LOC)
What is:
B. Narrowing pulse pressure