Show:
Congestive Heart Failure
Pulmonary Edema
Chronic Heart Failure
Disorders of Veins and Lymphatics
Peripheral Vascular Disease- Raynauds
100
A nurse is monitoring an infant with CHF which of the following alerts the nurse to suspect fluid accumulation and the need to call the physician? a. Bradypnea b. Diaphoresis c. Hypotension d. Weight gain of 1 lb in 1 day
Answer: D A weight gain of 1lb in one day is caused by accumulation of fluid. The nurse should assess urine output and assess for peripheral edema, auscultate lung sounds, and report the weight to the physician. Tachypnea and hypertension would occur with fluid accumulation. Diaphoresis is a sign of CHF but is not specific to fluid accumulation and usually occurs with exertion during activities.
100
A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed? A. The patient is somnolent with decreased response to the family. B. The patient suddenly complains of chest pain and shortness of breath. C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs. D. The patient has a fever, chills, and loss of appetite.
Answer: B Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. A patient with pulmonary embolism will not be sleepy or have a cough with crackles on exam. A patient with fever, chills and loss of appetite may be developing pneumonia.
100
The client is prescribed digoxin (Lanoxin) for treatment of HR. Which of the following statements by the client indicates the need for further teaching by the nurse? A. "I should not get short of breath anymore." B. "This drug will help my heart muscle pump less." C. "I may notice my heart rate decrease." D. "I may feel tired during early treatment."
Answer: B Rationale: The ability to increase the strength of contractions is a characteristic of cardiac glycosides. It may result in a decrease in pulse. Initially the client may experience some fatigue. Symptoms of CHF, such as dyspnea, should improve.
100
When planning the care of the client with Buerger's disease, the nurse incorportates measures to help the client cope with with the lifestyle changes that are needed to control the diseas process. The nurse can accomplish this by: A. Consult with a dietician B. Pain management clinic C. Smoking cessation program D. Referral to a medical social worker
Answer: C- Smoking cessation program Rationale: Smoking is highly detrimental to the client with Buerger's disease and clients are recommended to stop completely. Smoking is a form of chemical dependency, and referral to a smoking cessation program may be helpful for many clients. For many, symptoms are relieved or alleviated when smoking stops. Options A, B, & D are not directly related to the physiology associated with the condition.
100
The client with Raynaud's disease asks the nurse, "Why do my fingers turn blue then white and hurt?" Which of the following is the best response? A. This is related to inflammation of small veins in the hand B. This is related to decreased upper arm circulation C. This is related to swelling and edema in the fingers and hand D. This is related to spasms of the small arteries in the fingers
Answer D: Raynaud's disease is characterized by episodes of intense vasospasm in the small arteries and arterioles of the fingers and sometimes toes.
200
The client's serum digoxin level is 2.2 ng/dL and the heart rate is 120 and irregular. The nurse expects to administer which of the following drugs? A. Digoxin immune Fab (Digibind) B. Furosemide (Lasix) 60 mg I.V. C. Digoxin 0.5 mg bolus I.V. D. Potassium 40 mEq added to I.V. fluids
Answer: A Rationale: Digibind binds and removes digoxin from the body and prevents toxic effects of digoxin overdose. A serum level of 2.2 is elevated, and the client is exhibiting signs of digoxin toxicity. The question does not indicate that the potassium level is low. Giving additional digoxin would exacerbate the toxicity. Giving Lasix may reduce potassium levels and contribute to increased toxicity.
200
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the client's breath sounds? A. Stridor B. Crackles C. Scattered rhonchi D. Diminished breath sounds
Answer: B Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.
200
The client is prescribed captopril (Capoten) for treatment of HF. The nurse teaches that the primary action of the drug is to A.Prevent influx of calcium B. Lower peripheral resistance and reduce blood volume C. Increase strength of ventricular contractions D. Increase heart rate
Answer: B Rationale: ACE inhibitors decrease peripheral resistance and reduce blood volume by enhancing the excretion of sodium and water. This results in decreased afterload and increased cardiac output.
200
True or False: Nicotine replacement is the treatment for Beurger's disease
False. Rationale: No treatment can cure Buerger's disease. The most effective way to half the disease process is to quit using tobacco products.
200
In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: A. Walking several times each day as an exercise program B. Keep the heat up so that the environment is warm C. Wearing TED hose during the day D. Using hydrotherapy for increasing oxygenation
Answer B: The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would be most likely increase pain.
300
A patient with a history of Congestive Heart Failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform? A. Ask the patient to lie down on the exam table. B. Draw blood for chemistry panel and arterial blood gas (ABG). C. Send the patient for a chest x-ray. D. Check blood pressure.
Answer: D A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe hypertension. Therefore, taking the patient's blood pressure should be the first action. Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it. Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment.
300
A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the physician and prepares to implement which priority interventions? Select all that apply. A. Administering oxygen B. Inserting a Foley catheter C. Administering furosemide (Lasix) D. Administering morphine sulfate intravenously E. Transporting the client to the coronary care unit F. Placing the client in a low Fowler's side-lying position
Answer: A, B, C, D Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.
300
Myocardial oxygen consumption increases as which of the following parameters increase? A. Preload, afterload, and cerebral blood flow B. Preload, afterload, and renal blood flow C. Preload, afterload, contractility, and heart rate D. Preload, afterload, cerebral blood flow, and heart rate
Answer: C Myocardial oxygen consumption increases as preload, afterload, renal contractility, and heart rate increase. Cerebral blood flow doesn’t directly affect myocardial oxygen consumption.
300
Because of the diagnosis of Buerger's disease, the nurse collects which of the following about the client's history? A. Extended period of cigarette smoking B. Susceptibility to infection C. Recent onset of muscle twitching D. Increase apprehension
Answer: A Rationale: Cigarette smoking is the single most cause of the disease. Clients need health promotion and maintenance.
300
A patient who has been diagnosed with vasopastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient? A. An adolescent male B. An elderly women C. A young women D. An elderly man
Answer C: Raynaud's disease is most common in young women and is frequently associated with rheumatologic disorders, such as Lupus and RA.
400
A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct? A. "Stop taking the nitroglycerin and see if the headaches improve." B. "Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain." C. "Headaches are a frequent side effect of nitroglycerine because it causes vasodilation." D. "The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation."
Answer: C Nitroglycerin is a potent vasodilator and often produces unwanted effects such as headache, dizziness, and hypotension. Patients should be counseled, and the dose titrated, to minimize these effects. In spite of the side effects, nitroglycerine is effective at reducing myocardial oxygen consumption and increasing blood flow. The patient should not stop the medication. Nitroglycerine does not cause bleeding in the brain.
400
A client who has developed severe pulmonary edema would most likely exhibit which of the following? A. Mild anxiety B. Slight anxiety C. Extreme anxiety D. Moderate anxiety
Answer: C Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering.
400
Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. A. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output B. Activity intolerance related to increased cardiac output. C. Decreased cardiac output related to structural and functional changes. D. Impaired gas exchange related to decreased sympathetic nervous system activity.
A and C HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.
400
When treating Thrombophlebitis what is the most common medication given post operatively? a. Lasix b. Coumadin c. Asprin d. Heparin
Answer: D Rationale: heparin is most commonly given post-op to treat the formation of blood clots. This is given along with the prevention measures such as avoiding dehydration, preventing immobility, avoiding smoking, and the use of TED hose.
400
A client is experiencing more severe and frequent symptoms of Raynaud's disease. Which intervention would be appropriate for the nurse to discuss with the client? A. Adding a beta-blocker to the client's treatment plan B. Elevating the affected extremities during an attack C. Educating the client on the effects of a calcium channel blocker D. Describe an angioplasty procedure for the affected extremities
Answer C: Clients with Raynaud's disease are instructed to avoid cold and emotional stress; if symptoms become more frequent and severe, calcium channel blockers may be prescribed to reduce vasospasm. Beta blockers may worsen symptoms. Elevating the arm will decrease blood flow to the extremity. Angioplasty is a treatment for atherosclerotic arterial disease.
500
The nurse enters the room of the client diagnosed with CHF. The client is laying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? A. Sponge the client's forehead B. Obtain a pulse oximetry reading C. Take the patient's vital signs D. Assist the patient to a sitting position
Answer: D The nurse must first put the patient in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take the vital signs and check the pulse oximetry. Sponging the patient's forehead would be appropriate, but it is not the first intervention.
500
A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin (Lanoxin), the nurse should review which laboratory result? A. Sodium level B. Digoxin level C. Creatinine level D. Potassium level
Answer: D The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias.
500
A nurse is conducting a health history with a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure? A. Recent URI B. Nutritional anemia C. Peptic ulcer disease D. A-Fib
Answer:C Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget’s disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.
500
What are the factors in Thrombus formation? Select all that apply. a. Stasis of blood flow b. Decreased coagulation of the blood c. Increased coagulation of the blood d. Damage to the lining of the vein wall e. Changes in amount of blood in the body
Answer: A,C,D Rationale: Virchows triangle describes the three factors that are associated with thrombus formation. These factors are venous stasis, damage to vein wall, and increased coagulation of blood. A decreased coagulation of blood would not cause Thrombus and a change in the amount of blood in the body would not cause there to be Thrombus formation.
500
The nurse is teaching a client with Raynaud's disease to prevent having vasospasm. The nurse should discuss which of the following lifestyle changes with this client? Select all that apply. A. Stop smoking B. Exercise fingers by using the keyboard or playing the piano C. Wear mittens when taking food out of the freezer D. Warm up the car before driving in cold weather E. Stop vasospasm by putting the affected part in the ice water
Answer A,C,D: The nurse instructs the client to prevent vasospasm by taking measures to keep extremities warm, such as wearing mittens when exposed to cold temperatures and warming the car before driving in cold weather. The nurse also advises the client to stop smoking, as nicotine is a vasoconstrictor. Repetitive motions with a keyboard or piano can induce symptoms. The client can stop the vasospasm by putting the hands or feet in warm water.