Chapter 29
Showing posts with label Chapter 29. Show all posts
Showing posts with label Chapter 29. Show all posts

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:

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:


a) acute pulmonary edema.

b) right-sided heart failure.

c) cardiogenic shock.

d) pneumonia.



Answer: acute pulmonary edema.

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?

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) Mechanical ventilation

b) Intubation

c) A mask

d) A nasal cannula



Answer: A mask

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 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?


a) Hold the medication and call the physician.

b) Administer the hydralazine and hold the dinitrate.

c) Administer a saline bolus of 250 mL and then administer the medication.

d) Administer the medication and check the blood pressure in 30 minutes.



Answer: Hold the medication and call the physician.

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?

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) Low-sodium diet

b) Low-cholesterol diet

c) Low-potassium diet

d) Low-fat diet



Answer: Low-sodium diet

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?

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?


a) "I sleep on three pillows each night."

b) "I don't have the same appetite I used to."

c) "My pants don't fit around my waist."

d) "My feet are bigger than normal."


Answer: "I sleep on three pillows each night."

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?

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) Left atrial function

b) Left ventricular function

c) Right atrial function

d) Right ventricular function



Answer: Left ventricular function

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 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) Administer angiotensin-converting enzyme inhibitors

b) Administer diuretics

c) Assess oxygen saturation level

d) Administer angiotensin II receptor blockers



Answer: Assess oxygen saturation level

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 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) Tuberculosis

b) Bilateral pneumonia

c) Acute exacerbation of chronic obstructive pulmonary disease

d) Decompensated heart failure with pulmonary edema



Answer: Decompensated heart failure with pulmonary edema

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 physician orders digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?


a) Sodium level of 152 mEq/L

b) Magnesium level of 2.5 mg/dl

c) Potassium level of 2.8 mEq/L

d) Calcium level of 7.5 mg/dl



Answer: Potassium level of 2.8 mEq/L

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 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) Attach a pulse oximeter probe and obtain values.

b) Observe for mist in the endotracheal tube.

c) Call for a chest x-ray.

d) Listen for breath sounds over the epigastrium.



Answer: Call for a chest x-ray.

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 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) Complete blood count (CBC)

b) B-type natriuretic peptide (BNP)

c) Serum electrolytes

d) Blood urea nitrogen (BUN)



Answer: B-type natriuretic peptide (BNP)

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:

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:


a) nocturia and sleep disturbances.

b) taste and smell alterations.

c) dry mouth and urine retention.

d) visual disturbances.



Answer: visual disturbances.

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