Nokea
A cardiac patients resistance to left ventricular filling has caused blood to back up into the patients circulatory system. What health problem is likely to result?
- A. Acute pulmonary edema
- B. Right-sided HF
- C. Right ventricular hypertrophy
- D. Left-sided HF
Correct Answer: A
Rationale: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided HF, left-sided HF, and right ventricular hypertrophy do not directly occur.
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Diagnostic imaging reveals that the quantity of fluid in a clients pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication?
- A. Pulmonary edema
- B. Pericardiocentesis
- C. Cardiac tamponade
- D. Pericarditis
Correct Answer: C
Rationale: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiological process.
The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.
- A. Facilitate the presence of friends and family whenever possible
- B. Teach the patient about the harmful effects of anxiety on cardiac function
- C. Provide supplemental oxygen, as needed
- D. Provide validation of the patients expressions of anxiety
- E. Administer benzodiazepines two to three times daily
Correct Answer: A,C,D
Rationale: The nurse should empathically validate the patients sensations of anxiety. The presence of friends and family are frequently beneficial and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some patients, but alternative methods of relief should be prioritized. As well, medications are administered on a PRN basis. Teaching the patient about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.
The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure?
- A. Jugular vein distention
- B. Right upper quadrant pain
- C. Bibasilar fine crackles
- D. Dependent edema
Correct Answer: C
Rationale: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply.
- A. Platelet level
- B. Fluid status
- C. Cardiac rhythm
- D. Action of medications
- E. Sputum volume
Correct Answer: B,C,D
Rationale: The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels and sputum production are not major assessment parameters in a patient who is experiencing cardiogenic shock.
The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurses rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm?
- A. Pulseless electrical activity (PEA)
- B. Ventricular fibrillation
- C. Ventricular tachycardia
- D. Asystole
Correct Answer: D
Rationale: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.