Heart Failure
A nurse is caring for a patient with acute heart failure and fluid overload. Which of the following interventions would be the priority?
a) Administer furosemide 20 mg/min IV
b) Restrict fluid intake to 500 mL daily
c) Increase oxygen to 6 L/min via nasal cannula
d) Position the patient in a supine position to maximize circulation
Correct answer: a) Administer furosemide 20 mg/min IV
Explanation:
For fluid overload in heart failure, the primary goal is to reduce the excess fluid in the body. Furosemide (a loop diuretic) helps reduce fluid retention, which is essential in treating heart failure with fluid overload. Administering the diuretic is the first step to manage this condition and alleviate symptoms like edema, shortness of breath, and pulmonary congestion.
A patient with heart failure (HF) is admitted to the hospital with pulmonary congestion and fluid overload. The nurse plans to administer furosemide (Lasix) IV to help reduce fluid buildup. Which of the following interventions should the nurse prioritize while monitoring this patient?
a) Monitor serum potassium levels regularly.
b) Encourage fluid intake to prevent dehydration.
c) Assess for hyperglycemia due to diuretic therapy.
d) Increase sodium intake to prevent electrolyte imbalance.
Correct answer: a) Monitor serum potassium levels regularly.
Explanation:
A nurse is preparing to administer digoxin to a patient with mitral valve regurgitation. The patient has a heart rate of 56 bpm. Which of the following actions should the nurse take before administering the medication?
a) Administer the medication as prescribed, as long as the heart rate is above 50 bpm.
b) Hold the medication and notify the healthcare provider.
c) Increase the heart rate by administering a beta blocker.
d) Administer the medication after checking the patient's potassium levels.
**Correct answer: b) Hold the medication and notify the healthcare provider.
a) "Mitral stenosis occurs when the mitral valve does not close properly, causing blood to flow back into the left atrium."
b) "Mitral stenosis is caused by the narrowing of the mitral valve, which obstructs blood flow from the left atrium to the left ventricle."
c) "Mitral stenosis leads to an increase in cardiac output by forcing more blood through the narrowed mitral valve."
d) "Mitral stenosis causes blood to flow backward into the right atrium, leading to right-sided heart failure."
Correct answer: b) "Mitral stenosis is caused by the narrowing of the mitral valve, which obstructs blood flow from the left atrium to the left ventricle."
Explanation: Mitral stenosis refers to the narrowing of the mitral valve, which impairs blood flow from the left atrium to the left ventricle. As a result, the left atrium becomes distended, and pulmonary congestion develops due to increased pressure in the lungs.
A nurse is reviewing the ABG results of a patient with metabolic alkalosis. Which of the following findings would be most indicative of this condition?
a) pH: 7.48 (Normal: 7.35–7.45)
b) PaCO2: 40 mmHg (Normal: 35–45 mmHg)
c) HCO3-: 30 mEq/L (Normal: 22–26 mEq/L)
d) PaO2: 95 mmHg (Normal: 80–100 mmHg)
Correct answer: c) HCO3-: 30 mEq/L
A nurse is assessing a patient receiving digoxin. Which of the following findings would indicate digoxin toxicity?
a) Hypotension and nausea
b) Hyperkalemia and confusion
c) Bradycardia and visual disturbances
d) Tachycardia and vomiting
Correct answer: c) Bradycardia and visual disturbances
Explanation: Digoxin toxicity can manifest as bradycardia (slowed heart rate) and visual disturbances, such as yellow or green halos around lights. These are classic signs of digoxin toxicity, which can occur due to high serum levels or electrolyte imbalances (particularly low potassium).
A nurse is performing a cardiovascular assessment on a patient with heart failure. Which of the following findings should the nurse immediately report to the healthcare provider?
a) S3 heart sound
b) Pitting edema of lower extremities
c) Orthopnea
d) Weight gain of 3 pounds in 24 hours
Correct answer: d) Weight gain of 3 pounds in 24 hours
Explanation:
Rapid weight gain (typically 2-3 pounds in 24 hours) is an important early sign of fluid retention in heart failure and should be immediately reported to the healthcare provider. This could indicate worsening fluid overload, which may require adjustments in treatment (e.g., increasing diuretics, assessing kidney function, etc.).
Implementation of Care
A nurse is caring for a patient with pericarditis. The patient is experiencing sharp chest pain. Which of the following is the most appropriate nursing intervention?
a) Encourage deep breathing exercises
b) Position the patient flat in bed for comfort
c) Administer NSAIDs and monitor vital signs
d) Increase fluid intake to prevent dehydration
The correct answer is c) Administer NSAIDs and monitor vital signs.
Explanation:
Pericarditis is inflammation of the pericardium (the sac surrounding the heart). One of the hallmark symptoms of pericarditis is sharp, pleuritic chest pain that often worsens with deep breathing and improves when the patient leans forward. This pain is typically due to the inflammation of the pericardial lining.
The mainstay of treatment for pericarditis involves anti-inflammatory medications, such as NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), which help reduce the inflammation and alleviate the pain. Monitoring vital signs is important to ensure that there are no complications, such as cardiac tamponade, where fluid accumulates in the pericardial sac, causing pressure on the heart.
A patient with mitral valve prolapse reports chest pain and fatigue. Which of the following assessments would be most important?
a) Auscultate for S3 heart sound
b) Measure blood pressure and pulse
c) Assess for edema and weight gain
d) Evaluate for shortness of breath and orthopnea
The correct answer is b) Measure blood pressure and pulse.
Explanation:
Mitral valve prolapse (MVP) is a condition where the mitral valve's leaflets bulge (prolapse) into the left atrium during systole. In many cases, MVP is asymptomatic or has mild symptoms, but it can cause chest pain, fatigue, and other issues like palpitations.
When a patient with mitral valve prolapse reports chest pain and fatigue, it’s important to first assess blood pressure and pulse to evaluate for any signs of hemodynamic compromise or arrhythmias.
A patient with chronic obstructive pulmonary disease (COPD) presents with a pH of 7.32 (7.35-7.45), PaCO2 of 55 mm Hg (35-45 mm Hg), and HCO3 of 26 mEq/L (22–26 mEq/L). The nurse recognizes this as:
a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis
Correct answer: a) Respiratory acidosis
Explanation:
This patient's ABG values indicate respiratory acidosis:
A nurse is providing post-procedure care for a patient who has just undergone a Percutaneous Coronary Intervention (PCI). Which of the following interventions should the nurse prioritize?
a) Encourage the patient to ambulate as soon as possible to prevent blood clots.
b) Maintain the head of the bed elevated to 45 degrees to promote comfort.
c) Monitor the puncture site for bleeding or hematoma formation.
d) Provide a high-sodium diet to help restore fluid balance.
Correct answer: c) Monitor the puncture site for bleeding or hematoma formation.
Explanation: Following a Percutaneous Coronary Intervention (PCI), monitoring the puncture site for signs of bleeding or a hematoma is a priority.
A patient who underwent mitral valve replacement with a mechanical valve is being discharged from the hospital. The nurse is teaching the patient about long-term care. Which of the following instructions should the nurse include in the teaching plan?
a) "You will need to take anticoagulants for the rest of your life to prevent blood clots."
b) "You will need to stop taking anticoagulants as soon as your INR reaches 3."
c) "You can stop taking antibiotic prophylaxis for endocarditis once your valve has healed."
d) "You will need to limit your physical activity to prevent strain on the heart.
Correct answer: a) "You will need to take anticoagulants for the rest of your life to prevent blood clots."
A nurse is monitoring a patient with pericarditis for signs of cardiac tamponade. Which of the following findings would the nurse expect?
a) Hypertension and bounding pulses
b) Tachycardia and distant heart sounds
c) Peripheral edema and jugular vein distention
d) Increased urine output and fever
Correct answer: b) Tachycardia and distant heart sounds
Explanation:
Cardiac tamponade occurs when fluid accumulates in the pericardial sac, putting pressure on the heart and impairing its ability to fill properly. This results in reduced cardiac output and can lead to hypotension and signs of heart failure.
A nurse is assessing a patient with mitral valve regurgitation. Which of the following findings would the nurse expect during the assessment?
Correct answer: b) Chest pain, dyspnea, orthopnea, and palpitations
Explanation:
Mitral valve regurgitation occurs when the mitral valve does not close properly, causing blood to flow backward into the left atrium during systole. This leads to volume overload in the left atrium and left ventricle, and over time, it can contribute to symptoms of heart failure (specifically left-sided heart failure).
A nurse is assessing a patient with metabolic acidosis. Which of the following findings would the nurse expect to observe in this patient?
a) Shallow, rapid breathing
b) Kussmaul respirations
c) Decreased respiratory rate
d) Deep, slow breathing
Correct answer: b) Kussmaul respirations
Explanation: Kussmaul respirations are deep, rapid breathing patterns that occur as the body attempts to compensate for metabolic acidosis by exhaling more carbon dioxide (CO₂) to increase the pH of the blood. This is a compensatory mechanism to counteract the acidosis. The body increases ventilation to blow off excess CO₂, which is acidic, in an effort to raise the blood's pH and restore balance.
A 68-year-old male patient with a history of coronary artery disease and hypertension is admitted with acute decompensated heart failure (ADHF). The nurse is reviewing his diagnostic results and clinical signs. Which of the following findings would most likely indicate worsening left-sided heart failure? (Select all that apply.)
a) Presence of an S3 heart sound
b) Decreased oxygen saturation (SpO2) levels
c) Jugular venous distention (JVD)
d) Presence of crackles in the lung bases
e) Increased BNP levels
f) Sudden weight gain of 2 kg (4.4 lbs) in 24 hours
Correct answers:
A nurse is caring for a patient with mitral valve regurgitation who has been admitted with acute decompensated heart failure (ADHF). The patient’s vital signs are:
On assessment, the nurse notes dyspnea, orthopnea, and an S3 heart sound. The patient is also pale and diaphoretic. The healthcare provider orders a 12-lead ECG, echocardiogram, and IV furosemide.
Which of the following actions should the nurse take first?
a) Administer the prescribed IV furosemide to reduce fluid overload
b) Prepare the patient for immediate valve replacement surgery
c) Administer oxygen to improve oxygen saturation
d) Evaluate the 12-lead ECG for signs of arrhythmias
c) Administer oxygen to improve oxygen saturation
Explanation: The first priority in patients with acute decompensated heart failure (ADHF) and signs of hypoxia is to improve oxygenation. The patient’s low O2 saturation (88%) and signs of dyspnea indicate a need for oxygen therapy. Once the patient's oxygenation improves, further interventions like diuretic therapy with IV furosemide can be implemented to manage the fluid overload and alleviate symptoms like orthopnea and dyspnea.
A nurse is assessing a patient diagnosed with aortic stenosis. Which of the following findings would the nurse most likely observe in the patient? (Select all that apply.)
a) Dyspnea on exertion and at rest
b) Angina (chest pain)
c) Syncope (fainting) during physical activity
d) Increased jugular venous distention (JVD)
e) S3 heart sound on auscultation
Correct answers:
A nurse is reviewing the medical history of a patient with mitral stenosis. Which of the following are risk factors that the nurse should identify as contributing to the development of mitral stenosis? Select all that apply.
a) Rheumatic fever
b) Radiation to the chest
c) Endocarditis
d) Family history of valve disease
e) Female gender
Correct answers:
A patient with metabolic acidosis is receiving treatment. Which of the following interventions should the nurse prioritize when caring for this patient?
a) Administer sodium bicarbonate to correct the acid-base imbalance.
b) Monitor hourly urine output and ensure it is at least 30 mL/hr.
c) Encourage the patient to take deep breaths to compensate for the acidosis.
d) Increase the patient's fluid intake to promote renal function.
Correct answer: b) Monitor hourly urine output and ensure it is at least 30 mL/hr.
A nurse is caring for a patient receiving digoxin for heart failure. The nurse should monitor for which of the following signs or symptoms, as they could indicate digoxin toxicity? (Select all that apply.)
a) Bradycardia
b) Confusion
c) Elevated blood pressure
d) Visual disturbances, such as yellow halos
e) Nausea and vomiting
f) Hypokalemia
Correct answers:
A nurse is providing education to a patient with heart failure who has been prescribed digoxin. Which of the following statements made by the patient indicate an understanding of the medication regimen? (Select all that apply.)
a) “I should check my pulse before taking this medication, and if it is below 60 beats per minute, I will not take the medication.”
b) “I will eat foods high in potassium, such as bananas, to help prevent digoxin toxicity.”
c) “I will contact my doctor if I experience any visual disturbances, such as seeing halos around lights.”
d) “It is important to take digoxin with meals to avoid stomach upset.”
e) “I should monitor my blood pressure daily, and if it falls below 100/60 mmHg, I should hold the medication.”
Correct answers:
A nurse is assessing a patient with mitral valve prolapse (MVP). Which of the following findings would the nurse expect to observe in this patient? Select all that apply.
a) Dyspnea not related to activity
b) Chest pain not related to activity
c) Excessive weight gain
d) Shortness of breath on exertion
e) Fatigue and palpitations
Explanation: Mitral valve prolapse (MVP) is a condition where the mitral valve’s leaflets bulge (prolapse) into the left atrium during systole. Although MVP is often asymptomatic, it can cause symptoms in some patients, including these.
A nurse is assessing a patient with valve disease. Which of the following are common findings in patients with valve disease? Select all that apply.
a) Asymptomatic for many years
b) Heart murmurs
c) Signs of heart failure
d) Arrhythmia or stroke
e) Atrial fibrillation
f) Increased blood pressure
Correct answers: a) Asymptomatic for many years, b) Heart murmurs, c) Signs of heart failure, d) Arrhythmia or stroke, e) Atrial fibrillation (AFib), f) Increased blood pressure (BP)
Explanation: In the early stages of valve disease, patients may often be asymptomatic for many years because the body compensates for changes in the heart. However, as the disease progresses, symptoms can develop.
A nurse is caring for a patient who has been diagnosed with respiratory acidosis due to chronic obstructive pulmonary disease (COPD). Which of the following nursing interventions should the nurse prioritize? (Select all that apply.)
a) Administer oxygen therapy to improve oxygen saturation and reduce CO2 retention.
b) Encourage the patient to perform deep breathing exercises to increase ventilation and expel CO2.
c) Monitor the patient's ABG levels, especially for pH and PaCO2 levels.
d) Provide bronchodilators and steroids to improve airway function and facilitate gas exchange.
e) Maintain the patient’s head of bed at 45 degrees to optimize lung expansion.
Correct answers: