rationale-heart failure.docx

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 5th Edition

Test Bank

Chapter 38: Interventions for Clients with Cardiac Problems

MULTIPLE CHOICE

1. A client with heart failure develops an increase in preload. What pathophysiologic process is responsible for these changes?

A. A reduction in sympathetic stimulationB. Stimulation of coronary baroreceptorsC. Activation of the renin-angiotension-aldosterone systemD. Arterial vasodilation and subsequent increase in oxygen consumption

ANS: CCompensatory mechanisms in the body initially assist in increasing cardiac output, but eventually these contribute to pump failure. Activation of the renin-angiotension-aldosterone system increases preload by contributing to vasoconstriction and fluid retention, which, in turn, reduce the force of contraction and cardiac output.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: N/AMSC: Client Needs Category: Physiological Integrity

2. A client is admitted with early-stage heart failure. What immediate compensatory response would the nurse expect to see in this client?

A. Decreased stroke volume causing decreased urinary outputB. Arterial vasodilation resulting in pooling of blood in the extremitiesC. Stimulation of adrenergic receptors causing an increase in heart rateD. Myocardial hypertrophy resulting in an initial increase in oxygen saturation

ANS: CIn heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: AnalysisMSC: Client Needs Category: Physiological Integrity

3. A client with systolic dysfunction has an ejection fraction of 38%. What pathophysiologic changes would the nurse expect to follow?

A. An increase in stroke volumeB. A decrease in tissue perfusionC. An increase in oxygen saturationD. A decrease in arterial vasoconstriction

ANS: BIn 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.


4. Which client is most at risk of developing left-sided heart failure?A. 52-year-old female with mitral valve diseaseB. 60-year-old male with pulmonary hypertensionC. 48-year-old female who smokes two packs of cigarettes dailyD. 72-year-old male who has had a right ventricular myocardial infarction

ANS: AAlthough most individuals 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. Causes of left ventricular failure include mitral or aortic valve disease, CAD (coronary artery disease), and hypertension.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: AssessmentMSC: Client Needs Category: Physiological Integrity

5. Which statement made by a client would alert the nurse to the possibility of heart failure?

A. “I am 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.”

ANS: CClients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living.


6. A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What action should the nurse take at this time?

A. Instruct the client to come to the clinic for evaluation.B. Instruct the client to increase fluid intake during waking hours.

C.Instruct the client to use an over-the-counter cough suppressant before going to sleep.

D.Instruct the client to use two pillows to facilitate drainage of postnasal secretions.

ANS: AThe client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible.


7. Which statement made by a client would alert the nurse to the possibility of right-sided heart failure?

A. “I sleep with four pillows at night.”B. “My shoes fit really tight.”C. “I wake up coughing every night.”D. “I have trouble catching my breath.”

ANS: BSigns of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system and peripheral edema develops.

DIF: Cognitive Level: Application TOP: Nursing Process Step: AnalysisMSC: Client Needs Category: Physiological Integrity

8. What is the ejection fraction for a 60-year-old woman whose left ventricular end-diastolic volume is 125 mL and left ventricular end-systolic volume is 55 mL?

A. 26%B. 40%C. 56%D. 70%

ANS: CEjection fraction is the percentage of blood leaving the left ventricle with systolic contraction (stroke volume). The stroke volume is calculated by subtracting the volume remaining in the left ventricle after systolic contraction (55 mL) from the volume in the left ventricle at the end of diastole (125 mL), or 70 mL. In this situation, the stroke volume (70 mL) is 56% of the total left ventricular end-diastolic volume (125 mL).

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: Assessment

MSC: Client Needs Category: Physiological Integrity

9. With which of the following clients should the nurse remain alert to the possible development of high-output heart failure?

A. 40-year-old woman taking oral contraceptivesB. 40-year-old man who broke an ankle while training for a marathonC. 68-year-old man with dehydration 5 years after having a myocardial infarction

D.27-year-old woman taking excessive amounts of thyroid hormone to promote weight loss

ANS: DHyperthyroidism, whether caused by increased synthesis of thyroid hormones or overdose of exogenous thyroid hormone, increases heart rate and contractility. Such an increase can increase the workload of the heart without allowing sufficient time for perfusion and oxygenation.


10. A nurse is performing a cardiac assessment on a client with heart failure. In assessing the client’s apical pulse, the nurse notes the pulse to be displaced to the left. What conclusion can be drawn from this assessment?

A. This is a normal finding.B. The heart is hypertrophied.C. The left ventricle is contracted.D. The client is experiencing pulsus alternans.

ANS: BThe client with heart failure typically has a hypertrophied heart that displaces the apical pulse to the left.


11. During auscultation of the heart of a client with left ventricular failure, the nurse notes the presence of a third heart sound (S3) gallop. What can the nurse infer from this finding?

A. Left ventricular pressure is increased.B. There is a decrease in ventricular compliance.C. The client has been noncompliant with the medication regimen.D. The client should be prepared for transfer to the intensive care unit.

ANS: AThe presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure.

DIF: Cognitive Level: Application or higher

TOP: Nursing Process Step: AssessmentMSC: Client Needs Category: Physiological Integrity

12. A nurse is performing auscultation of the posterior lungs of a client admitted with heart failure. There are increasing crackles from the bases to the lower third of both lungs. What would be the nurse’s best action?

A. Place the client in a semirecumbent position.B. Increase the intravenous fluid rate.C. Administer chest physiotherapy.D. Notify the health care provider.

ANS: DIncreasing crackles indicate worsening of heart failure. The health care provider should be notified so preventive action can be taken to avoid complications, such as pulmonary edema.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: InterventionMSC: Client Needs Category: Physiological Integrity

13. The client with right heart failure asks the nurse to explain the necessity of taking a daily weight. What would be the nurse’s best response?

A. “Weight is the best indication that you are gaining or losing fluid.”B. “Weighing you every day will help us adjust your medication.”C. “It is required that all inpatients be weighed daily.”D. “Being overweight contributes to heart failure.”

ANS: ADaily weights are needed to document fluid retention because the presence of edema is not a reliable sign of heart failure.


14. A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What primary collaborative problem should the nurse be most alert for in this client?

A. Risk for aspirationB. Potential for acidosisC. Risk for activity intoleranceD. Potential for pulmonary edema

ANS: DThe client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: Analysis


15. Which nursing diagnosis would be considered a priority for the client with heart failure?

A. Anxiety related to hospitalizationB. Altered Health MaintenanceC. Impaired Gas ExchangeD. Altered Comfort

ANS: CThe client with heart failure experiences impaired gas exchange related to inadequate cardiac pump function. Although all other diagnoses presented here may be manifested, Impaired Gas Exchange is the priority because it is the most life threatening.


16. The client with heart failure is experiencing respiratory difficulty. Which is the nurse’s best intervention?

A. Place the client in the high-Fowler’s position.B. Suction the client.C. Auscultate the client’s heart and lungs.D. Place the client on fluid restriction.

ANS: APlacing a client in the high-Fowler’s position with pillows under each arm can maximize chest expansion and improve oxygenation.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: ImplementationMSC: Client Needs Category: Physiological Integrity

17. The client with heart failure is prescribed to take enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which of the following precautions or instructions should the nurse teach this client regarding drug therapy?

A. Avoid salt substitutes.B. Be sure to take this medication with food.C. Avoid aspirin or aspirin-containing products while on this medication.D. Do not take this medication if your pulse rate is below 74 beats/min.

ANS: AACE inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: Planning


18. A 76-year-old client with heart failure has been prescribed captopril, an ACE inhibitor. What nursing intervention would be most appropriate when giving the first dose of this medication?

A. Administer this medication 1 hour before meals to aid absorption.B. Instruct the client to ask for assistance when arising from the bed.C. Give the medication with milk to prevent stomach upset.D. Monitor for hypokalemia.

ANS: BAdministration of the first dose of ACE inhibitors is associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from the bed to prevent injury from postural hypotension.


19. The client with heart failure is being treated with digoxin and has developed hypokalemia. What action should the nurse prepare to take?

A. Administer digoxin twice daily.B. Reduce the digoxin dose to every other day.C. Administer an intravenous bolus of potassium.D. Monitor the client for toxic effects that can occur at normal doses.

ANS: DDigoxin exerts its effects by binding to the potassium receptor site (competing with potassium) on the myocardial membrane. When serum potassium levels are below normal, more potassium receptor sites are bound with digoxin, allowing it to exert a greater effect at the same dosage.


20. The client with moderate heart failure is going home. Which of the following activities or interventions will assist the client to identify a worsening of the condition?

A. Avoid drinking more than 3 quarts of liquids each day.B. Stop your activity and rest at the first sign of chest pain.C. Weigh yourself every day at the same time wearing the same amount of clothes.D. If you forget to take your digoxin one day, do not take two doses the next day.

ANS: CWeight gain is the most reliable indicator of fluid retention associated with heart failure.


21. The client who has just been started on isosorbide dinitrate (Isordil) complains of a headache. What is the nurse’s best first action?

A. Titrate oxygen to relieve headache.B. Hold the next dose.C. Notify the physician.D. Administer prescribed PRN acetaminophen.

ANS: DThe vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen.


22. The client with heart failure has been ordered to receive a daily nitroglycerin transdermal patch. What action taken by the nurse would help avoid tolerance to the vasodilating effects of this medication?

A. Place an occlusive dressing over the patch.B. Remove the patch overnight.C. Rotate the skin site of nitroglycerin administration.D. Administer a larger loading dose before the initiation of therapy.

ANS: BProviding a 12-hour nitrate-free period out of every 24 hours helps prevent the development of tolerance to the vasodilating effects of nitrates.


23. What precautions/instructions should the nurse provide to the client initiating chronic digoxin therapy?

A. Avoid taking aspirin or aspirin-containing products.B. Increase your fluid intake to at least 3000 mL daily.C. Do not take this medication if your pulse rate is below 80 beats/min.D. Do not take this medication within 1 hour of taking an antacid.

ANS: DGastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: Implementation


24. A client admitted with heart failure who is taking a thiazide diuretic has been ordered to receive furosemide (Lasix). What side effect of these medications should the nurse be alert for?

A. CoughB. HeadacheC. BradycardiaD. Hypokalemia

ANS: DHypokalemia is a side effect of both thiazide and loop diuretics.


25. Which of the following clinical manifestations in a client being treated for heart failure who is undergoing progressive increase in activity indicates activity intolerance?

A. Oxygen saturation of 95%B. Respiratory rate of 26 breaths/minC. Systolic blood pressure change from 136 to 96 mm HgD. Heart rate increase from 86 to 110 beats/min

ANS: CA blood pressure change (increase or decrease) of more than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease in blood pressure during or following activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: EvaluationMSC: Client Needs Category: Physiological Integrity

26. A 70-year-old client with heart failure has developed atrial fibrillation. What laboratory test would the nurse expect to be ordered for this client?

A. Anion gapB. Serum sodium levelC. T4 and TSH (thyroid-stimulating hormone) levelsD. Serum creatinine level

ANS: CIn older adults with atrial fibrillation, T4 and TSH levels should be checked because hypo- or hyperthyroidism can cause or aggravate heart failure.


27. Which clinical manifestation should alert the nurse to the possibility of impending pulmonary edema in a 75-year-old client with heart failure?

A. ConfusionB. DysphagiaC. Sacral edemaD. Irregular heart rate

ANS: AIn older adults with heart failure, impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs.


28. A client with a history of heart failure is being discharged home. What discharge instructions will assist the client in the prevention of complications associated with heart failure?

A. Drink at least 2 L of fluids daily.B. Eat six small meals daily instead of three larger meals.C. When you feel short of breath, take an additional diuretic.D. Weigh yourself daily wearing the same amount of clothing.

ANS: DClients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure are increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.


29. A client has been admitted to the acute care unit for an exacerbation of heart failure. Which of the following nursing actions should be performed first?

A. Assessment of respiratory and oxygenation statusB. Monitoring of serum electrolyte levelsC. Administration of intravenous fluidsD. Insertion of a Foley catheter

ANS: AAssessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications.


30. What assessment data obtained by the home care nurse suggest that the client with heart failure has poor tissue perfusion?

A. The client has a right carotid bruit.B. The client has a dry, hacking cough.C. The client has a positive Allen’s test.D. The client has dyspnea while performing activities of daily living (ADLs).

ANS: DIndications of poor tissue perfusion are activity intolerance, particularly with normal activities, fatigue, changes in mental status, and pallor or cyanosis.


31. The client has a mitral valve prolapse. Which of the following heart sounds should the nurse expect to auscultate with this client?

A. Rumbling apical diastolic murmurB. Midsystolic click and late systolic murmurC. An S3 coupled with a high-pitched systolic murmurD. Continuing, loud diastolic murmur radiating to the left axilla

ANS: BThe mitral valve separates the left atrium from the left ventricle. The prolapse permits backflow of blood during mid- to late systole, resulting in a midsystolic click and a late systolic murmur at the heart apex.


32. A client with mitral stenosis presents to the clinic for a follow-up visit. What clinical manifestation alerts the nurse to the possibility that the client may be experiencing a worsening of this condition?

A. The client’s oxygen saturation is 92%.B. The client has dyspnea on exertion.C. The client has a systolic crescendo-decrescendo murmur.D. The client experiences a loss of strength in the upper extremities.

ANS: BThe development of dyspnea on exertion occurs as the mitral valvular orifice narrows and pressure in the lungs increases.

DIF: Cognitive Level: N/A TOP: Nursing Process Step: N/AMSC: Client Needs Category: N/A

33. A client has been diagnosed with aortic stenosis. What alteration in the client’s vital signs would the nurse expect to find upon assessment?

A. A bounding arterial pulse

B. A slow, faint arterial pulseC. A narrowed pulse pressureD. Elevated systolic and diastolic pressures

ANS: CIn aortic stenosis, the client presents with a narrowed pulse pressure when the blood pressure is assessed.


34. A client has been diagnosed with mitral insufficiency. Which clinical manifestation would the nurse expect when assessing the client?

A. Systolic click on auscultationB. High-pitched holosystolic murmurC. Angina with exertionD. Cough with hemoptysis

ANS: BIncomplete closure of the mitral valve allows backflow of blood into the left atrium when the ventricle contracts, resulting in a holosystolic, high-pitched murmur.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: AssessmentMSC: Client Needs Category: Physiological Integrity

35. The client who has had a prosthetic valve replacement asks his nurse why he must take anticoagulants for the rest of his life. What is the nurse’s best response?

A.“You are now at greater risk for a heart attack, and the anticoagulants can reduce that risk.”

B.“Blood clots form more easily on replacement valves and areas inside the heart where stitches have been placed.”

C.“The vein taken from your leg reduces circulation in the leg, making blood return to the heart much slower.”

D.“The surgery left a lot of small clots in your heart and lungs; the anticoagulants will slowly dissolve these unnecessary clots.”

ANS: BSynthetic valve prostheses and scar tissue provide a surface on which platelets can aggregate easily and initiate the formation of blood clots.


36. A client has just undergone a balloon valvuloplasty. What complication of this procedure should the nurse monitor this client for?

A. BleedingB. Acute tubular necrosis

C. Short-term memory lossD. Pulmonary hypertension

ANS: AClients undergoing valvuloplasty are at higher risk of bleeding from the catheter insertion site because of the use of a large-bore catheter for the arterial puncture needed to perform the procedure. The nurse institutes precautions for arterial puncture, if necessary.


37. A client is preparing to be discharged home following mitral valve replacement. What statement made by the client indicates that the client requires further clarification?

A. “I won’t be able to carry heavy loads for at least 6 months.”B. “I will have my teeth cleaned by the dentist in 2 weeks.”C. “I will avoid eating foods high in vitamin K.”D. “I can use my electric razor to shave.”

ANS: BClients who have defective or repaired valves are at high risk of endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk of endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics.

DIF: Cognitive Level: Application or higherTOP: Nursing Process Step: EvaluationMSC: Client Needs Category: Physiological Integrity

38. A 35-year-old client presents with a fever, symptoms of heart failure, and a new heart murmur. What additional historical data should the nurse obtain?

A. Family history of coronary artery diseaseB. Recent travel to equatorial or third-world countriesC. Whether the client is responsible for cleaning pet litter boxesD. History of any systemic infection or dental work within the past month

ANS: DThe clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia.


39. What specific precautions or category of isolation should the nurse use when providing care to a client with infective endocarditis?

A. Standard precautions

B. Enteric precautionsC. Protective isolationD. Respiratory isolation

ANS: AThe client with infective endocarditis does not pose any specific threat of transmitting the endocarditis.


40. The home care nurse is assessing the client receiving antibiotic therapy in the home for infective endocarditis. Which of the following clinical manifestations requires re-evaluation of the treatment regimen?

A. FeverB. Fingernail clubbingC. Resolving petechiaeD. Pulse pressure of 36 mm Hg

ANS: APersistent or new fever in a client receiving antibiotic therapy for infective endocarditis may indicate inappropriate or ineffective therapy.


41. A nurse is providing care to a client with pericarditis and notes increasing difficulty in auscultating the client’s heart sounds. What is the nurse’s best first action?

A. Use a Doppler to assess heart sounds.B. Increase the intravenous flow rate.C. Administer oxygen by mask.D. Notify the physician.

ANS: DHeart sounds that become muffled or more difficult to auscultate in a client with pericarditis may indicate the presence of tamponade, a medical emergency.


42. Which clinical manifestation in a client with pericarditis should the nurse expect to find when performing a cardiac assessment?

A. An irregular heart rate that speeds up and slows downB. A friction rub at the left lower sternal borderC. The presence of a gallop rhythmD. A substernal lift at the apex

ANS: BThe client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together.


43. A nurse is caring for a client admitted with tachycardia, a pericardial friction rub, and the development of a new murmur. Which element of the client’s history would lead the nurse to suspect this client has rheumatic carditis?

A. The client was vacationing in the tropics 2 weeks ago.B. The client has had a sore throat for 1 week.C. The client is currently taking antibiotics.D. The client has a history of alcoholism.

ANS: BRheumatic carditis is a sensitivity response occurring after infection with group A beta-hemolytic streptococci. The client’s history of a sore throat is suspicious for rheumatic carditis in light of the clinical manifestations at admission.


44. Which instructions should be included as part of a teaching plan for a client with hypertrophic cardiomyopathy (HCM)?

A. “Take your digoxin at the same time every day.”B. “You should begin an aerobic exercise program.”C. “You should report episodes of dizziness or fainting.”D. “You may have a maximum of two drinks containing alcohol daily.”

ANS: CThe client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur, because they may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM.


45. Why should the nurse caution the client who has received a heart transplant to change positions slowly?

A. Rapid position changes can create shear forces and disrupt vascular sutures.

B.The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure.

C.The new heart is denervated and unable to respond to decreases in blood pressure caused by position changes.

D.The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.

ANS: CBecause the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops when positions are changed do not function, allowing orthostatic hypotension to persist in the postoperative period.


46. The client being discharged after a heart transplant is prescribed to take cyclosporine and azathioprine to prevent rejection of the new heart. Which of the following precautions should the nurse teach the client regarding this medication regimen?

A. Use a soft-bristled tooth brush.B. Avoid crowds and people who are sick.C. Drink at least 3 L of fluids each day.D. Do not take this medication if your pulse rate is lower than 60 beats/min.

ANS: BThese agents cause immunosuppression, leaving the client more vulnerable to infection.


47. Which ethical concern is most likely to have an impact on heart transplantation?A. Obtaining an appropriate donor matchB. How to allocate donated hearts fairlyC. Having the client pay for the procedureD. The cost of immunosuppressant medications

ANS: BThe best way to allocate donated hearts is an unresolved ethical issue because of the scarcity of this resource. The question of whether a donated heart should be given to the most critically ill client or to one who is more likely to have a longer post-transplant survival is still being debated.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: AnalysisMSC: Client Needs Category: Safe, Effective Care Environment;

rationale-heart failure.docx

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