Heart Failure
What are some signs of left sided heart failure?
Crackles at lung bases
Orthopena
Red frothy sputum
weak pulses
SOB
Which rhythm is most consistent with this finding?
Regular rhythm; P wave before each QRS; rate 50/min
Sinus bradycardia
What is coronary artery disease?
CAD involves atherosclerotic narrowing of coronary arteries that can reduce myocardial blood flow.
client taking an antihypertensive reports dizziness when standing. What nursing action is most appropriate?
Assess orthostatic BP/HR and institute fall precautions as indicated.
Read the passage and identify the TWO phrases the nurse should highlight as priority cues of worsening heart failure.
Mr. J. says he has been sleeping in a recliner for the last two nights because he becomes short of breath when lying flat. His weight is up 2.5 kg from his usual morning weight. He says his appetite is unchanged. His skin is warm and dry. He denies chest pain.
sleeping in a recliner because he becomes short of breath when lying flat
weight is up 2.5 kg from his usual morning weight
On a standard ECG, the interval that reflects conduction from the beginning of atrial depolarization through AV-node conduction to the beginning of ventricular depolarization is the __________ interval.
PR
What are some behavior changes to reduce CAD risk?
Exercise
Reduce stress
Stop/reduce alcohol consumption
Increase sleep
Diet low in fats
What finding most strongly helps the nurse distinguish peripheral arterial disease from a venous circulation problem?
Cool, pale extremity with diminished distal pulses
A client with heart failure has worsening pulmonary congestion. The nurse notes oxygen saturation of 86% on room air and increasing dyspnea. The nurse should first position the client in what position to improve ventilation and reduce venous return?
High Fowlers
A client on a cardiac monitor has the following rhythm strip description: the rhythm is rapid and regular, QRS complexes are wide, and P waves are not clearly associated with the QRS complexes.
Which feature should the nurse identify as the cues supporting ventricular tachycardia?
Wide QRS complexes
Rapid regular rhythm
No clear P-QRS relationship
A client with known CAD develops new crushing substernal chest pressure radiating to the jaw with diaphoresis. What hypothesis should the nurse prioritize?
Acute myocardial ischemia/possible acute coronary syndrome
A hospitalized client suddenly develops unilateral calf swelling, warmth, and tenderness. What should you not do?
Encourage vigorous ambulation immediately
apply a heating pad and reassess in 4 hours
A client with heart failure has dyspnea, crackles, and oxygen saturation 84% on room air. Which action should the nurse take first?
Position upright
apply prescribed oxygen
rapidly reassess respiratory status.
Which rhythm is most consistent with this finding?
Irregularly irregular rhythm; no distinct P waves
Atrial fibrillation
What education is needed for a patient taking nitroglycerin?
Use it as prescribed for chest pain and seek emergency help for persistent/severe symptoms according to the prescribed plan.
do not exceed 3 doses taken 5 minutes apart
The nurse is caring for a client with hypertension whose BP remains above the prescribed target. What actions support safe management?
Assess medication adherence and barriers to adherence.
Review the client's home BP readings and technique.
Assess for symptoms and signs of target-organ effects.
Collaborate with the provider when BP remains uncontrolled
A client with heart failure has increasing edema, weight gain, and sodium 128 mEq/L. Which hypothesis should the nurse prioritize?
Fluid-volume excess with possible dilutional hyponatremia
Which rhythm is most consistent with this finding?
Wide QRS complexes at a rapid regular rate; P waves not clearly associated
Ventricular tachycardia
A client with CAD develops chest pressure that began 20 minutes ago and is not relieved by rest. The client is pale and diaphoretic. What is the priority nursing action?
Treat the symptoms as possible acute coronary syndrome and activate the prescribed emergency response while assessing ABCs
MONA
A client with hypertension is being discharged after BP stabilization. What actions support a safe and effective care environment?
Verify the client understands the medication schedule.
Use teach-back to confirm understanding of warning signs.
Provide a plan for follow-up BP monitoring.
Reconcile the medication list before discharge.