Med or class of med
Labs
Signs/Symptoms/Stages
Nursing Interventions
NCLEX Questions
100

Prevents the conversion of angiotensin I to angiotensin II

What are ace inhibitors

100

This needs monitored for the client taking Furosemide

What is potassium

100

Crackles, SOB, fatigue

What is left sided heart failure

100

Risk for Falls

Alarm

Nonskid footwear

Close to nurses station

Lighting

100

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

200

Increases the renal excretion of water, sodium, chloride, magnesium, calcium, and potassium

What is Furosemide

200

Lab value most often used to assist with diagnosis of heart failure

What is BNP

200

Trigger release of renin, ADH, aldosterone, epinephrine, norepinephrine to start kidney compensation

What is:

Non-progressive or Compensatory stage

200

Impaired Gas Exchange

O2 sat

Oxygen

Positioning

lung sounds


200

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

300

Reduce autonomic nervous system effects by blocking beta-1 adrenergic receptor sites in the heart

What are Beta Blockers

300

Produced in the liver, makes up about 60% of total protein in the blood, can be used to determine nutritional status

What is albumin

300

Pitting edema, weight gain, distended neck veins

What is right sided heart failure

300

Fluid Volume Excess

assess for edema

elevate extremities

weight

fluid restriction

salt restriction

300

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

400

Increases myocardial contractility. Must have an apical pulse prior to administration

What is Digoxin

400

Carries oxygen to and removes CO2 from red blood cells. Also serves as a buffer to maintain acid-base balance

What is Hemoglobin

400

MAP Drops >20mmHg

Cool moist skin, 

rapid, weak pulse

What is:

Progressive or Immediate Stage

400

Fluid Volume Deficit

IV replacement            color or urine/spec. gravity

Labs                            Mucus membranes

safety (BP, etc)

Skin turgor

I & O


400

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

500

Vasodilator to lower BP and decrease how hard the heart has to work

What are:

Hydralazine

Nitrates

500

Evaluate respiratory function and provide a measure for determining acid-base balance

What are:

ABG's

500

Rapid LOC, nonpalpable pulse,

Cold, dusky extremities

What is Refractory or Irreversible stage

500

Impaired Physical Mobility

Safety

Reposition

Assess skin

Rest periods

ROM


500

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