Valvular Disorders
Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of post-surgery activity restrictions. Which of the following should the client not engage in until after the 1-month post-discharge appointment with the surgeon?
1. Showering.
2. Lifting anything heavier than 10 lb (4.5 kg).
3. A program of gradually progressive walking.
4. Light house work.
2. Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge.
The nurse should assess the client with left-sided heart failure for which of the following? Select all that apply.
1. Dyspnea.
2. Jugular vein distention (JVD).
3. Crackles.
4. Right upper quadrant pain.
5. Oliguria.
6. Decreased oxygen saturation levels
1, 3, 5, 6. Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure.
A client is to have a Schilling test. The nurse should:
1. Administer methylcellulose.
2. Start a 24- to 48-hour urine specimen collection.
3. Maintain nothing-by-mouth (NPO) status.
4. Start a 72-hour stool specimen collection.
2. Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24- to 48-hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of nonradioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorptive state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Methylcellulose is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not a part of the Schilling test. If stool contaminates the urine collection, the results will be altered.
The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client?
1. Administration of digoxin
2. Administration of whole blood
3. Administration of intravenous fluids
4. Administration of packed red blood cells
1. The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed red blood cells are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided.
The most important long-term goal for a client with hypertension is to:
1. Learn how to avoid stress.
2. Explore a job change or early retirement.
3. Make a commitment to long-term therapy.
4. Lose weight.
3. Compliance is the most critical element of hypertension therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management is an important component of hypertension therapy, but the priority goal is related to compliance. It is not necessary for the client to change jobs or retire, but rather to learn to manage stress if the job is stressful. Losing weight may be necessary and will contribute to lower blood pressure, but the client must first accept the need for a lifelong management plan to control the hypertension.
A client has mitral stenosis and will have a valve replacement. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time?
1. Medication therapy.
2. Diet modification.
3. Activity restrictions.
4. Dental care.
1. Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprosthesis are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does.
Which of the following sets of conditions is an indication that a client with a history of left- sided heart failure is developing pulmonary edema? Select all that apply.
1. Distended jugular veins
2. Dependent edema
3. Anorexia
4. Coarse crackles
5. Tachycardia
4, 5. Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.
The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet?
1. Eggs.
2. Lettuce.
3. Citrus fruits.
4. Cheese.
1. One of the microcytic, hypochromic anemias is iron deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green, leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.
Which of the following is the most important goal of nursing care for a client who is in shock?
1. Manage fluid overload.
2. Manage increased cardiac output.
3. Manage inadequate tissue perfusion.
4. Manage vasoconstriction of vascular beds.
3. Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.
The nurse is developing a care plan with an older adult with hypertension and is instructing the client that hypertension can be a “silent killer.” The nurse should instruct the client to report signs of which of the following diseases that are often a result of undetected high blood pressure?
1. Cerebrovascular accidents (CVAs).
2. Liver disease.
3. Myocardial infarction.
4. Pulmonary disease.
1. Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVAs can be related to long-term hypertension. Liver or pulmonary disease is not generally associated with hypertension. Myocardial infarction is generally related to coronary artery disease.
A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?
1. A low, grade 1 intensity mitral regurgitation murmur.
2. SpO2 is 94% on 2 L of oxygen via nasal cannula.
3. The client has become more somnolent.
4. Urine output has decreased from 60 mL/h to 40 mL over the last hour.
2. The nurse should verify that the physician has requested to withhold the Glucophage prior to any procedure requiring dye such as a cardiac catheterization due to the increased risk of lactic acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure involving dye while it clears the client's system. The physician may prescribe sliding scale insulin during this time if needed. Regardless of how or when the medication is administered, the medication should be withheld. The amount of protein in the client's diet prior to the cardiac catheterization has no correlation with the medication or the test.
The nurse should teach the client that signs of digoxin toxicity include which of the following?
1. Rash over the chest and back.
2. Increased appetite.
3. Visual disturbances such as seeing yellow spots.
4. Elevated blood pressure.
3. Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with digoxin toxicity.
The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first:
1. Discontinue the IV catheter if a blood transfusion reaction occurs.
2. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle.
3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution.
4. Stay with the client during the first 15 minutes of infusion.
4. The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established IV line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution?
1. Fluid balance.
2. Anaphylactic reaction.
3. Pain.
4. Altered level of consciousness.
2. The client who is receiving a blood product requires astute assessment for signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching), urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction occurs, the nurse should stop the transfusion immediately, but leave the IV line intact, and notify the physician. Usually, an antihistamine such as diphenhydramine hydrochloride (Benadryl) is administered. Epinephrine and corticosteroids may be administered in severe reactions. Fluid balance is not an immediate concern during the blood administration. The administration should not cause pain unless it is extravasating out of the vein, in which case the IV administration should be stopped. Administration of a unit of blood should not affect the level of consciousness.
The client has had hypertension for 20 years. The nurse should assess the client for:
1. Renal insufficiency and failure.
2. Valvular heart disease.
3. Endocarditis.
4. Peptic ulcer disease.
1. Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension.
Which is the most important initial post-procedure nursing assessment for a client who has had a cardiac catheterization?
1. Monitor the laboratory values.
2. Observe neurologic function every 15 minutes.
3. Observe the puncture site for swelling and bleeding.
4. Monitor skin warmth and turgor.
3. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.
When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply.
1. Becoming increasingly short of breath at rest.
2. Weight gain of 2 lb (0.9 kg) or more in 1 day.
3. High intake of sodium for breakfast.
4. Having to sleep sitting up in a reclining chair.
5. Weight loss of 2 lb (0.9 kg) in 1 day.
1, 2, 4. If the client will call the physician when there is increasing shortness of breath, weight gain over 2 lb (0.9 kg) in 1 day, and need to sleep sitting up, this indicates an understanding of the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the physician if he or she had consumed a high-sodium breakfast. Instead the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future.
A client is admitted from the emergency department after falling down a flight of stairs at home. The client's vital signs are stable, and the history states that the client had a gastric stapling 2 years ago. The client jokes about being clumsy lately and tripping over things. The nurse should ask the client which of the following questions? Select all that apply.
1. “Are you experiencing numbness in your extremities?”
2. “How much vitamin B12 are you getting?”
3. “Are you feeling depressed?”
4. “Do you feel safe at home?”
5. “Are you getting sufficient iron in your diet?”
1, 2, 3, 4. The nurse should ask the client about symptoms related to pernicious anemia because the client had the stomach stapled 2 years ago and shows no history of supplemental vitamin B12. Numbness and tingling relate to a loss of intrinsic factor from the gastric stapling. Intrinsic factor is necessary for absorption of vitamin B12. The nurse should suspect pernicious anemia if the client is not taking supplemental vitamin B12. Other signs and symptoms of pernicious anemia include cognitive problems and depression. The nurse also should ask about the client's support at home in case the fall was not an accident. Pernicious anemia is not related to dietary intake of iron.
A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take?
1. Call the primary health care provider immediately.
2. Document these findings, which are expected.
3. Re-evaluate the neurovascular status in 1 hour.
4. Increase the rate of the intravenous nitroglycerin infusion.
1. The nursing interventions for the client with an intra-aortic balloon pump are the same as for any client who has had cardiovascular surgery. The peripheral circulation to the affected limb is monitored for signs of occlusion, such as coolness, mottling, pain, tingling, and decreased or absent distal pulse. Adverse changes are reported immediately. The remaining options are incorrect.
A client diagnosed with primary (essential) hypertension is taking chlorothiazide (Diuril). The nurse determines teaching about this medication is effective when the client makes the following statement. “I will (Select all that apply.)
1. take my weight daily at the same time each day.”
2. not drink alcoholic beverages while on this medication.”
3. reduce salt in take in my diet.”
4. reduce my dosage if I have severe dizziness.”
5. use sunscreen if I have prolonged exposure to sunlight.”
6. take the drug late in the evening.”
1, 2, 3, 5. Chlorothiazide (Diuril) causes increased urination and decreased swelling (if there is edema) and weight loss. It is important to check and record weight two to three times per week at same time of day with similar amount of clothing. Clients should not drink alcoholic beverages or take other medications without the approval of the health care provider. Reducing sodium intake in the diet helps diuretic drugs to be more effective and allows smaller doses to be taken. Smaller doses are less likely to cause adverse effects and hence excessive table salt as well as salty foods should be avoided. Chlorothiazide (Diuril) is a diuretic that is prescribed for lower blood pressure and may cause dizziness and faintness when the patient stands up suddenly. This can be prevented or decreased by changing positions slowly. If dizziness is severe, the health care provider must be notified. Diuretics may cause sensitivity to sunlight, hence the need to avoid prolonged exposure to sunlight, use sunscreens, and wear protective clothing. Chlorothiazide (Diuril) causes increased urination and must be taken early in the day to decrease nighttime trips to the bathroom. Fewer bathroom trips mean less interference with sleep and less risk of falls.
A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks? Select all that apply.
1. Administer all prescribed oral medications.
2. Check for iodine sensitivity.
3. Verify that written consent has been obtained.
4. Withhold food and oral fluids before the procedure.
5. Insert a urinary drainage catheter.
2, 3, 4. For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.
The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?
1. Assess respiratory status.
2. Draw blood for laboratory studies.
3. Insert a Foley catheter.
4. Weigh the client.
1. The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.
A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?
1. Notify the attending physician and blood bank.
2. Complete the appropriate Transfusion Reaction Form(s).
3. Stop the transfusion.
4. Keep the IV open with normal saline infusion.
3. Stop the transfusion.
4. Keep the IV open with normal saline infusion.
1. Notify the attending physician and blood bank.
2. Complete the appropriate Transfusion Reaction Form(s).
When the client is having a blood transfusion reaction, the nurse should first stop the transfusion and then keep the IV open with normal saline infusion. Next, the nurse should notify the physician and blood bank, then complete the required form(s) regarding the transfusion reaction.
An adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse should determine that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which value in the normal range?
1. 56% (0.56)
2. 48% (0.48)
3. 37% (0.38)
4. 34% (0.34)
2. The normal hematocrit level for an adult male is 42% to 52% (0.42 to 0.52). The client who is in shock has an elevated level because of hemoconcentration. The client's level may be expected to drift back down to within the normal range once fluid volume has been adequately restored. Thus, 48% (0.48) is the only correct choice; 56% (0.56) is too high, and 34% (0.34) and 37% (0.37) are low.
A client who has diabetes is taking metoprolol (Lopressor) for hypertension. Which of the following information should the nurse include in the teaching plan? Select all that apply
1. These tablets should be taken with food at same time each day.
2. Do not crush or chew the tablets.
3. Notify the health care provider if pulse is 82 per minute.
4. Have a blood glucose level drawn every 6 to 12 months during therapy.
5. Use an appropriate decongestant if needed.
6. Report any fainting spells to the health care provider.
1, 2, 4, 6. Metoprolol (Lopressor) is a beta-adrenergic blocker indicated for hypertension, angina, and myocardial infarction. The tablets should be taken with food at same time each day; they should not be chewed or crushed. The health care provider should be notified if pulse falls below 50 for several days. Blood glucose should be checked regularly during therapy since increased episodes of hypoglycemia may occur. It may mask evidence of hypoglycemia such as palpitations, tachycardia, and tremor. Use of any OTC decongestants, asthma and cold remedies, and herbal preparations must be avoided. Fainting spells may occur due to exercise or stress, and the dosage of the drug may need to be reduced or discontinued.