Chapter 25: Complications of Heart Disease 1. A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence? a. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. 2. A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload? a. Head of the bed elevated 45 degrees and lower arms supported by pillows 3. When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating a. Orthopnea 4. A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber? a. heart rate of 55 beats per minute 5. The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided heart failure? a. Ascites 6. A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity? a. Visual disturbances 7. A nurse is teaching a client about heart failure. What will the nurse explain is causing the heart to fail? a. The heart cannot pump sufficient blood to meet the body's metabolic needs. 8. The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed? a. heart transplant 9. A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure? a. Right-sided heart failure 10. A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client? a. Nausea and vomiting 11. The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart? a. Echocardiogram 12. The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? a. Brain natriuretic peptide (BNP) 13. A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured? a. Echocardiogram 14. Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest? a. IV (four) 15. A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment? a. moist, gurgling respirations 16. A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first? a. Mask 17. The nurse is preparing to administer hydralazine and isosorbide dinitrate. When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse? a. Hold the medication and call the health care provider 18. The nurse identifies which symptom as a characteristic of right-sided heart failure? a. Jugular vein distention (JVD) 19. The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? a. Dizziness 20. Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone? a. Monitor blood pressure frequently 21. The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure? a. Pitting edema 22. A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of a. pulmonary embolism. 23. A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client? a. Pulmonary congestion 24. The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? a. Dyspnea on exertion 25. The nurse recognizes which symptom as a classic sign of cardiogenic shock? a. Restlessness and confusion 26. A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient’s ejection fraction to be? a. 30% 27. A client is receiving furosemide, a loop diuretic, to prevent fluid overload. The order is for 50 mg intravenous now. The pharmacy supplies furosemide 80 mg per 2 mL. How many mL will the nurse give the client? Round your answer and record to one decimal place. a. 1.3 28. A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? a. The development of left-sided heart failure 29. A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis? a. Orthopnea 30. Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole? a. Preload 31. A nurse is caring for a client with heart failure. The nurse knows that the client has leftsided heart failure when the client makes which statement? a. "I sleep on three pillows each night." 32. Which is a cerebrovascular manifestation of heart failure? a. Dizziness 33. The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival? a. Lisinopril 34. A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? a. BP and pulse measurements every 15 to 30 minutes 35. A client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition? a. acute pulmonary edema. 36. The nurse is performing an initial assessment of a client diagnosed with heart failure (HF) that includes the client's sensorium and level of consciousness (LOC). Why is the assessment of the client's sensorium and LOC important in clients with HF? a. HF ultimately affects oxygen transportation to the brain. 37. Which diagnostic study is usually performed to confirm the diagnosis of heart failure? a. Echocardiogram 38. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? a. Weighing the client daily at the same time each day 39. A client with a history of heart failure is returning from the operating room after inguinal hernia repair and the nurse assesses a low pulse oximetry reading. What is the most important nursing intervention? a. Titrate oxygen therapy 40. The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion? a. inadequate cardiac output 41. A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs? a. Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. 42. The pathophysiology of pericardial effusion is associated with all of the following except: a. Increased venous return 43. A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? a. JVD is noted 4 cm above the sternal angle. 44. A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor? a. Weight 45. The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with ordinary physical activity. Under what classification does the nurse understand this patient would be categorized? a. II (two) 46. Assessment of a client on a medical surgical unit finds a regular heart rate of 120 beats per minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 mL over the past hour. What is the reason the nurse anticipates transferring the client to the intensive care unit? a. The client is going into cardiogenic shock. 47. While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound? a. a third heart sound (S3).
