Question 1

The nurse is assisting with the care of a patient who is experiencing pulmonary edema.Which finding should the nurse expect to observe?

Accepted Answer

A)  Pedal edema 
B)  Sacral edema 
C)  Nausea/vomiting 
D)  Pink, frothy sputum

Question 2

A patient is diagnosed with a heart problem that affects preload.How should the nurse describe preload to the patient?

Accepted Answer

A)  Ejection of blood from ventricles 
B)  Degree of stretch in ventricles before systole 
C)  Degree of muscle stretch in atrium during diastole 
D)  Amount of force ventricles exert to open valves and eject blood

Question 3

A patient has been given bumetanide (Bumex)3 mg intravenously.Which action should the nurse take after this medication is administered?

Accepted Answer

A)  Monitor urine output. 
B)  Weigh the patient in 2 hours. 
C)  Listen to heart sounds for irregular heart rhythms. 
D)  Watch for leg cramps, and medicate if necessary.

Question 4

During a home visit,the nurse learns that a patient with chronic heart failure is planning to quit cardiac rehabilitation because of the fear of dying while on the treadmill.Which response by the nurse is best?

Accepted Answer

A)  "I don't blame you for feeling frustrated, I hate to exercise too." 
B)  "People don't die on the treadmill; it's to make your heart stronger." 
C)  "It sounds like you want to give up. I'll call the doctor and have you transferred to the hospice program." 
D)  "You sound upset. Did you know research shows that cardiac rehab programs give people better medical outcomes and a higher quality of life?"

Question 5

The nurse is contributing to a plan of care for a patient who has heart failure.What should be the major goal of nursing management for this patient?

Accepted Answer

A)  Increase fluid intake. 
B)  Reduce the workload of the heart. 
C)  Increase venous return to the heart. 
D)  Promote a decrease in cardiac output.

Question 6

A patient with lower extremity edema from heart failure is fatigued from constant sleep interruption to void.What should the nurse instruct the patient to promote uninterrupted rest?

Accepted Answer

A)  Take prescribed diuretics immediately before going to bed 
B)  Recline with the legs below heart level for 1 hour before going to bed 
C)  Sit with the legs crossed at the ankles for 1 to 2 hours before going to bed 
D)  Recline with the legs above heart level for 30 minutes before going to bed

Question 7

The nurse is reinforcing teaching provided to a patient with chronic heart failure who is scheduled for pacemaker placement.Which patient statement indicates that additional instruction is required?

Accepted Answer

A)  "I need to have this surgery to reduce the risk of sudden death." 
B)  "I won't have to take my cardiac medications after the surgery." 
C)  "The pacemaker helps treat my heart failure by making my heart pump regularly." 
D)  "The pacemaker will help keep a steady rhythm so blood is pumped more efficiently."

Question 8

During a visit to the home of a patient with heart failure and diabetes the nurse learns that the patient "feels strange." Data collected includes blood pressure 172/94 mm Hg,pulse 112 beats/min,respirations 22/min; heart rhythm regular; coarse crackles in lower lung bases.What action should the nurse take?

Accepted Answer

A)  Consult the RN. 
B)  Give the patient orange juice. 
C)  Assist patient to bed for a nap. 
D)  Recheck vital signs in 30 minutes.

Question 9

A patient with a potassium level of 3 mEq/L is to receive furosemide (Lasix)20 mg by mouth.What action should the nurse take?

Accepted Answer

A)  Give the Lasix 30 minutes early. 
B)  Give the Lasix as scheduled now. 
C)  Consult the RN before giving Lasix. 
D)  Hold this scheduled dose of the Lasix.

Question 10

A patient recovering from heart transplant surgery is shivering,has weak peripheral pulses,mottled skin on the feet,and excessive chest tube drainage.Which nursing diagnosis should the nurse recommend?

Accepted Answer

A)  Pain related to sternotomy and incisions 
B)  Decreased Cardiac Output due to hypovolemia 
C)  Risk for Impaired Skin/Tissue Integrity due to incision 
D)  Risk for Infection due to inadequate primary defenses from surgical wound and immunosuppression

Question 11

The nurse is teaching a patient with heart failure how to avoid activity that results in Valsalva's maneuver.Which observation indicates that teaching has been effective?

Accepted Answer

A)  The patient takes shallow breaths. 
B)  The patient uses a straw when drinking. 
C)  The patient strains while using the commode. 
D)  The patient breathes normally when sitting up.

Question 12

A patient is receiving potassium (K-Lor)20 mEq/L,furosemide (Lasix)20 mg,and digoxin (Lanoxin)0.125 mg orally.The patient's potassium level is 5.8 mEq/L and the dose of K-Lor 10 mEq/L is scheduled to be given now.What action should the nurse take?

Accepted Answer

A)  Monitor the urine output. 
B)  Give K-Lor as scheduled now. 
C)  Assess the patient's pulse rate. 
D)  Hold the scheduled dose of Lasix.

Question 13

The nurse is monitoring the chest tube drainage for a patient recovering from cardiac surgery.What volume should the nurse report to the charge nurse?

Accepted Answer

A)  50 mL/hr 
B)  100 mL/hr 
C)  150 mL/hr 
D)  225 mL/hr

Question 14

A patient is receiving potassium (K-Lor)20 mEq/L,furosemide (Lasix)20 mg,and digoxin (Lanoxin)0.125 mg orally.The patient's potassium level is 4 mEq/L and urine output for the last 8 hours was 350 mL.What should the nurse do about the prescribed medications?

Accepted Answer

A)  Inform the RN. 
B)  Hold the scheduled dose of Lasix. 
C)  Give medications as scheduled now. 
D)  Hold the scheduled dose of Lanoxin.

Question 15

The nurse is contributing to a plan of care for a patient who has had a 5 pound weight gain in 2 days,pitting edema of the ankles,lung crackles,and distended neck veins.Which nursing diagnosis would be given priority in the plan of care?

Accepted Answer

A)  Noncompliance 
B)  Urinary Retention 
C)  Excess Fluid Volume 
D)  Ineffective Health Maintenance

Question 16

The nurse reinforced teaching for a patient awaiting a heart transplant.Which statements indicate that the patient understands the usual criteria used for a potential heart donor? (Select all that apply.)

Accepted Answer

A)  Age less than 55 years 
B)  No hypertension or diabetes 
C)  Absence of malignant disease 
D)  Presence of no active infections 
E)  Presence of no significant cardiac disease
F) Weight within 35 lb of prospective recipient

Question 17

The nurse is collecting data from a patient who is receiving digoxin (Lanoxin),0.125 mg daily.Which finding should indicate to the nurse that the patient is experiencing side effects of the medication?

Accepted Answer

A)  Bradycardia 
B)  Constipation 
C)  Skin flushing 
D)  Muscle cramps

Question 18

The nurse is reinforcing teaching provided to a patient prescribed captopril (Capoten).What should the nurse specifically include in instructions? (Select all that apply.)

Accepted Answer

A)  Take medication with meals. 
B)  Report any cough that develops. 
C)  Use sunscreen to prevent photosensitivity. 
D)  Check blood pressure weekly and report changes. 
E)  Report to the laboratory weekly for laboratory follow-up.
F) Report any swelling of the hands, feet, or tongue or difficulty swallowing.

Exam 26: Nursing Care of Patients With Heart Failure

The nurse is assisting with the care of a patient who is experiencing pulmonary edema.Which finding should the nurse expect to observe?

A patient is diagnosed with a heart problem that affects preload.How should the nurse describe preload to the patient?

A patient has been given bumetanide (Bumex) 3 mg intravenously.Which action should the nurse take after this medication is administered?

During a home visit,the nurse learns that a patient with chronic heart failure is planning to quit cardiac rehabilitation because of the fear of dying while on the treadmill.Which response by the nurse is best?

The nurse is contributing to a plan of care for a patient who has heart failure.What should be the major goal of nursing management for this patient?

A patient with lower extremity edema from heart failure is fatigued from constant sleep interruption to void.What should the nurse instruct the patient to promote uninterrupted rest?

The nurse is reinforcing teaching provided to a patient with chronic heart failure who is scheduled for pacemaker placement.Which patient statement indicates that additional instruction is required?

A patient with a potassium level of 3 mEq/L is to receive furosemide (Lasix) 20 mg by mouth.What action should the nurse take?

A patient recovering from heart transplant surgery is shivering,has weak peripheral pulses,mottled skin on the feet,and excessive chest tube drainage.Which nursing diagnosis should the nurse recommend?

The nurse is teaching a patient with heart failure how to avoid activity that results in Valsalva's maneuver.Which observation indicates that teaching has been effective?

A patient is receiving potassium (K-Lor) 20 mEq/L,furosemide (Lasix) 20 mg,and digoxin (Lanoxin) 0.125 mg orally.The patient's potassium level is 5.8 mEq/L and the dose of K-Lor 10 mEq/L is scheduled to be given now.What action should the nurse take?

The nurse is monitoring the chest tube drainage for a patient recovering from cardiac surgery.What volume should the nurse report to the charge nurse?

A patient is receiving potassium (K-Lor) 20 mEq/L,furosemide (Lasix) 20 mg,and digoxin (Lanoxin) 0.125 mg orally.The patient's potassium level is 4 mEq/L and urine output for the last 8 hours was 350 mL.What should the nurse do about the prescribed medications?

The nurse is contributing to a plan of care for a patient who has had a 5 pound weight gain in 2 days,pitting edema of the ankles,lung crackles,and distended neck veins.Which nursing diagnosis would be given priority in the plan of care?

The nurse reinforced teaching for a patient awaiting a heart transplant.Which statements indicate that the patient understands the usual criteria used for a potential heart donor? (Select all that apply.)

The nurse is collecting data from a patient who is receiving digoxin (Lanoxin) ,0.125 mg daily.Which finding should indicate to the nurse that the patient is experiencing side effects of the medication?

The nurse is reinforcing teaching provided to a patient prescribed captopril (Capoten) .What should the nurse specifically include in instructions? (Select all that apply.)