A physician in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
a) Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
b) Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours
c) A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling
d) A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling
Answer: Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
Chapter 29
- A client with left-sided heart failure complains of 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:
- Eighty six-year-old Susan Matthews has been rushed to the ED with pulmonary edema during your shift. She is going to need oxygen immediately. Which oxygen delivery system do you use first?
- A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which of the following assessment findings for this client?
- The nurse is preparing to administer hydralazine and isosorbide dinitrate (Dilatrate). When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse?
- The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?
- A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?
- The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?
- A patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention?
- A nurse taking care of a patient recently admitted to the ICU observes the patient coughing up large amounts of pink, frothy sputum. Auscultation of the lungs reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this patient is developing which of the following problems?
- A physician orders digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?
- A nurse suspects that a client has digoxin toxicity. The nurse should assess for:
- On assessment, the nurse knows that a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity would have heart failure classified as Stage:
- A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?
- A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure?
- A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth daily, and furosemide (Lasix), 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause:
- The nurse is preparing to administer furosemide (Lasix) to a client with severe heart failure. What lab study should be of most concern for this client while taking Lasix?
- In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?
- Which of the following medications is a human brain natriuretic peptide (BNP) preparation?
- Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?
- The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer?
- A 73-year-old client has been admitted to the cardiac step-down unit where you practice nursing. After diagnostics, she was brought to your unit with acute pulmonary edema. Which of the following symptoms would you expect to find during your assessment?
- Which of the following is the hallmark of systolic heart failure?
- A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?
- Which of the following body system responses correlates with systolic heart failure (HF)?
- A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is: