Heart Failure
To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review?
a. Troponin
b. Homocysteine (Hcy)
c. Low-density lipoprotein (LDL)
d. B-type natriuretic peptide (BNP)
What is D?
Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).
To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should
a. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest.
b. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border.
c. ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub.
d. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.
What is B?
Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low-pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.
The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?
a. Reinforce the dressing.
b. Apply an abdominal binder.
c. Take the patient's vital signs.
d. Recheck the dressing in 1 hour for increased drainage.
What is C?
New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.
A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?
a. Administer the ordered opioid.
b. Check the oxygen (O2) saturation.
c. Take the blood pressure and pulse.
d. Apply wrist restraints to secure IV lines.
What is B?
Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action
When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for
a. diastolic murmur.
b. peripheral edema.
c. shortness of breath on exertion.
d. right upper quadrant tenderness.
What is C?
The pressure gradient changes in mitral stenosis lead to fluid back up into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia.
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first?
a. Start an IV line.
b. Place the patient on NPO status.
c. Administer O2 per nasal cannula.
d.Give lorazepam (Ativan) 1 mg IV.
What is B?
TEE is an invasive procedure and requires the client to be NPO to prevent aspiration.
When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include?
a. Monitor labs for streptococcal antibodies.
b. Arrange for placement of a long-term IV catheter.
c. Teach the importance of completing all oral antibiotics.
d. Encourage the patient to begin regular aerobic exercise.
What is B?
Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.
The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5 F (35.8 C). Which action should the nurse take?
a. Cover the patient with a warm blanket and put on socks.
b. Notify the anesthesia care provider about the temperature.
c. Avoid the use of opioid analgesics until the patient is warmer.
d. Administer acetaminophen (Tylenol) 650 mg suppository rectally.
What is A?
The patient assessment indicates the need for active rewarming.
The nurse educator facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse educator to intervene?
a. The student wears a mask at the sink area.
b. The student wears street clothes in an unrestricted area.
c. The student wears surgical scrubs in the semi-restricted area.
d. The student covers the head and facial hair in the semi-restricted area.
What is C?
Rationale: The surgical suite is divided into three distinct areas: unrestricted staff and others in street clothes can interact with those in surgical attire; semi-restricted staff must wear surgical attire and cover all head and facial hair; restricted include the operating room, the sink area, and clean core where masks are required in addition to surgical attire.
A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient?
a. Biologic valves will require immunosuppressive drugs after surgery.
b. Mechanical mitral valves need to be replaced sooner than biologic valves.
c. Lifelong anticoagulant therapy will be needed after mechanical valve replacement.
d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.
What is C?
Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed.
A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect?
a. A decrease in blood pressure and urine output
b. An increase in creatinine and extremity edema
c. An increase in heart rate and respiratory rate
d. A decrease in respirations and oxygen saturation
What is C?
In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings.
The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask?
a. Do you use any illegal IV drugs?
b. Have you had a recent sore throat?
c. Have you injured your chest in the last few weeks?
d. Do you have a family history of congenital heart disease?
What is B?
Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.
After receiving a change-of-shift report about these postoperative patients, which patient should the nurse assess first?
a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating
b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery
c. Patient who has bibasilar crackles and a temperature of 100F (37.8C) on the first postoperative day after chest surgery
d. A patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration
What is A?
The patient's history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon
A patient scheduled for an elective hysterectomy tells the nurse, I am afraid that I will die in surgery like my mother did! Which response by the nurse is most appropriate?
a.Tell me more about what happened to your mother.
b.You will receive medications to reduce your anxiety.
c.You should talk to the doctor again about the surgery.
d.Surgical techniques have improved a lot in recent years.
What is A?
The patient's statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements may also address the patient's concerns, but further assessment is needed first.
The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure?
a. “I sleep with four pillows at night.”
b. “My shoes fit really tight lately.”
c. “I wake up coughing every night.”
d. “I have trouble catching my breath.”
What is B?
Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure?
a. Middle-aged woman with aortic stenosis
b. Middle-aged man with pulmonary hypertension
c. Older woman who smokes cigarettes daily
d. Older man who has had a myocardial infarction
What is A?
Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.
The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate?
a. Do you have a history of a heart attack?
b. Is there a family history of endocarditis?
c. Have you had any recent immunizations?
d. Have you had dental work done recently?
What is D?
Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?
a. Perform a bladder scan.
b. Encourage increased oral fluid intake.
c. Assist the patient to ambulate to the bathroom.
d. Insert a straight catheter as indicated on the PRN order.
What is A?
The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.
A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take?
a. Notify the dietitian about the food allergies.
b. Alert the surgery center about a possible latex allergy.
c. Reassure the patient that all allergies are noted on the medical record.
d. Ask whether the patient uses antihistamines to reduce allergic reactions.
What is B?
Certain food allergies (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches) are related to latex allergies. When a patient is allergic to latex, special nonlatex materials are used during surgical procedures, and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available during surgery. The other actions also may be appropriate, but prevention of allergic reaction during surgery is the most important action.
A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change?
a. Increase in stroke volume
b. Decrease in tissue perfusion
c. Increase in oxygen saturation
d. Decrease in arterial vasoconstriction
What is B?
In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. Stroke volume and oxygen saturation do not increase with a low ejection fraction.
The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure?
a. “I have been drinking more water than usual.”
b. “I have been awakened by the need to urinate at night.”
c. “I have to stop halfway up the stairs to catch my breath.”
d. “I have experienced blurred vision on several occasions.”
What is C?
Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or “catching their breath.” This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.
When developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to include?
a. Vaccinate high-risk groups in the community with streptococcal vaccine.
b. Teach community members to seek treatment for streptococcal pharyngitis.
c. Teach about the importance of monitoring temperature when sore throats occur.
d. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.
What is B?
The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever.
Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?
a. Assist the patient to the bathroom and stay with the patient to prevent falls.
b. Offer a urinal or bedpan and position the patient in bed to promote voiding.
c. Allow the patient up to the bathroom because medication onset is 10 minutes.
d. Ask the patient to wait because catheterization is performed just before the surgery.
What is B?
The nurse is preparing to witness the patient signing the operative consent form when the patient says, I do not really understand what the doctor said. Which action is best for the nurse to take?
a. Provide an explanation of the planned surgical procedure.
b. Notify the surgeon that the informed consent process is not complete.
c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications.
d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.
What is B?
The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurses legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient understands the surgical procedure and signs the consent form.
A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse’s best action?
a. Place the client in a high Fowler’s position.
b. Begin cardiopulmonary resuscitation (CPR).
c. Promote rest and minimize activities.
d. Administer loop diuretics as prescribed.
What is D?
The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler’s position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.