Heart Failure
A patient with left-sided heart failure develops worsening dyspnea, crackles, and an oxygen saturation of 88%.
What complication is the nurse most concerned about?
Pulmonary Edema
A patient with heart failure has gained 2.2 kg (4.8 lb) in 3 days. The patient reports that their shoes feel tighter and the nurse notes bilateral crackles.
Which finding provides the strongest evidence that the weight gain is related to fluid retention?
A. Increased appetite
B. Bilateral crackles
C. Fatigue after walking
D. Heart rate of 92/min
B. Bilateral crackles
A patient with hypertension has a BP of 178/104 mmHg. Which assessment finding would be most concerning?
A. Mild fatigue
B. Headache with new confusion
C. Occasional dizziness when standing
D. Increased appetite
B. Headache with new confusion
A patient asks why coronary artery disease can eventually cause myocardial ischemia.
Explain why.
Atherosclerotic plaque narrows the coronary arteries, reducing blood flow and oxygen delivery to the myocardium.
A patient has cool skin, diminished pedal pulses, shiny hairless legs, and pain with walking that improves with rest.
Which condition is most consistent with these findings?
Peripheral arterial disease (PAD)
A patient with heart failure has JVD, peripheral edema, hepatomegaly, and weight gain.
These findings are most characteristic of which type of heart failure?
RIght-sided HF
A patient with heart failure takes furosemide daily. The patient reports muscle weakness and an irregular heartbeat. The nurse reviews the laboratory results.
Which result requires the most immediate intervention?
A. Sodium 134 mEq/L
B. Potassium 2.8 mEq/L
C. BUN 27 mg/dL
D. Creatinine 1.3 mg/dL
B. Potassium 2.8 mEq/L
A patient with long-standing hypertension reports headache, blurred vision, and chest pressure. BP is 214/118 mmHg.
What should the nurse recognize?
The patient may be experiencing a hypertensive emergency with possible target-organ damage.
A patient reports chest pressure that previously occurred only while climbing stairs and resolved with rest, but today the pain occurs while sitting and lasts 20 minutes.
What should the nurse recognize?
A. Expected stable angina
B. Progression to unstable angina
C. Gastroesophageal reflux
D. Musculoskeletal chest pain
B. Progression to unstable angina
A patient with chronic venous insufficiency has bilateral lower-leg edema, brown discoloration around the ankles, and a shallow ulcer near the medial malleolus.
What is the underlying problem causing these findings?
A. Arterial obstruction
B. Impaired venous return
C. Acute arterial embolism
D. Deep vein thrombosis
B. Impaired venous return
A patient with heart failure has gained 3 lb in 2 days. Which nursing action should occur first?
A. Encourage the patient to increase oral fluids
B. Assess lung sounds and respiratory status
C. Teach the patient about a low-sodium diet
D. Obtain a daily weight tomorrow morning
B. Assess lung sounds and respiratory status
Why: The rapid weight gain indicates fluid retention, and the immediate priority is determining whether pulmonary congestion is developing.
The nurse receives report on four patients. Which patient should the nurse assess first?
A. Heart failure patient with a 2-lb weight gain over 48 hours
B. Patient taking furosemide with potassium of 3.3 mEq/L
C. Heart failure patient with new crackles and an SpO₂ of 88%
D. Hypertensive patient with BP of 158/92 mmHg
C. Heart failure patient with new crackles and an SpO₂ of 88%
Don't automatically choose the "worst-looking number." New respiratory compromise = ABC priority.
The nurse receives report on four patients. Which patient should be assessed first?
A. BP 168/92 with no symptoms
B. BP 156/88 with a mild headache
C. BP 202/116 with new confusion and blurred vision
D. BP 174/96 who reports being nervous about their diagnosis
C. BP 202/116 with new confusion and blurred vision
Severe hypertension with neurologic changes suggests possible acute target-organ damage.
A patient with suspected MI reports chest pressure and nausea. Which finding provides the strongest evidence of myocardial injury?
A. Heart rate of 104/min
B. Diaphoresis
C. Elevated troponin
D. Blood pressure of 158/92 mmHg
C. Elevated troponin
Which assessment finding would help the nurse distinguish PAD from chronic venous insufficiency?
A. Lower-extremity edema
B. Leg discomfort
C. Skin changes
D. Diminished pedal pulses with a cool extremity
D. Diminished pedal pulses with a cool extremity
A patient with heart failure is receiving furosemide. Which laboratory value is most important for the nurse to monitor?
A. Sodium
B. Potassium
C. Hemoglobin
D. Platelets
B. Potassium
A patient with heart failure is receiving IV furosemide. Four hours later, the nurse notes:
Which finding should the nurse recognize as the highest priority cue?
A. Increased urine output
B. Hypotension
C. Potassium 2.7 mEq/L with palpitations
D. Respiratory rate of 24/min
C. Potassium 2.7 mEq/L with palpitations
Severe hypokalemia + cardiac symptoms = immediate risk of dysrhythmia.
A patient with chronic hypertension has a BP of 198/110 mmHg. The patient reports severe headache and seeing “flashing lights.” The nurse also notes new weakness in the right arm.
What is the nurse's priority action?
A. Recheck the BP in 30 minutes
B. Encourage the patient to rest quietly
C. Initiate rapid evaluation for possible target-organ damage
D. Provide education about a low-sodium diet
C. Initiate rapid evaluation for possible target-organ damage
A patient is admitted after an MI. Two hours later, the patient becomes suddenly short of breath and hypotensive. The nurse notes new crackles and an S3 heart sound.
Which complication should the nurse suspect?
A. Left-sided heart failure
B. Peripheral arterial disease
C. Deep vein thrombosis
D. Stable angina
A. Left-sided heart failure
A postoperative patient develops new unilateral calf swelling, warmth, and tenderness.
Which nursing action is most appropriate?
A. Massage the calf to improve circulation
B. Encourage the patient to ambulate
C. Notify the provider and anticipate diagnostic evaluation
D. Apply a heating pad and reassess in 4 hours
C. Notify the provider and anticipate diagnostic evaluation
A patient with heart failure suddenly develops severe dyspnea, anxiety, crackles throughout both lungs, pink frothy sputum, HR 124/min, and SpO₂ 82%.
Which action should the nurse take first?
A. Administer IV furosemide
B. Place the patient in high-Fowler's position and apply oxygen
C. Obtain a daily weight
D. Restrict sodium intake
B. Place the patient in high-Fowler's position and apply oxygen
A patient with heart failure receiving IV furosemide develops BP 82/48, HR 126, K⁺ 2.7 mEq/L, new palpitations, and decreased urine output. Which action should the nurse take first?
A. Administer the next dose of furosemide
B. Encourage oral fluids
C. Place the patient on a cardiac monitor and notify the provider
D. Administer prescribed potassium and reassess in 4 hours
C. Place the patient on a cardiac monitor and notify the provider
The combination of severe hypokalemia + palpitations + hypotension + decreased urine output indicates a potentially unstable patient with a high risk for dysrhythmia and impaired perfusion.
The nurse is caring for four patients with hypertension. Which patient requires immediate intervention?
A. BP 166/94 with no symptoms
B. BP 178/100 with a mild headache
C. BP 190/106 with chronic kidney disease and unchanged urine output
D. BP 186/108 with new confusion, unequal pupils, and right-sided weakness
D. BP 186/108 with new confusion, unequal pupils, and right-sided weakness
The new neurologic changes suggest acute target-organ damage, making this patient the priority.
A patient with CAD develops chest pressure while walking. The patient stops and rests, but the pain continues for 15 minutes. The patient is pale and diaphoretic, HR 112/min, BP 94/58 mmHg.
Which change is most concerning for progression from ischemia to myocardial infarction?
A. Pain occurring during activity
B. Tachycardia
C. Pain persisting despite rest with hypotension
D. History of coronary artery disease
C. Pain persisting despite rest with hypotension
A patient with PAD reports that their usual calf pain occurs only when walking. Today, the patient reports severe foot pain while resting and the foot is pale, cool, and has no palpable pedal pulse.
What should the nurse do?
A. Elevate the leg above heart level
B. Apply compression stockings
C. Notify the provider immediately
D. Encourage the patient to walk to improve circulation
C. Notify the provider immediately