Nokea
A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?
- A. Class I (Mild)
- B. Class II (Mild)
- C. Class III (Moderate)
- D. Class IV (Severe)
Correct Answer: A
Rationale: Class I is when ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.
You may also like to solve these questions
The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid, shallow breathing. Later, there is a shift to metabolic acidosis as gas exchange becomes more impaired.
A client is scheduled for a multiple gated acquisition (MUGA) scan the following day. What medication is contraindicated for the nurse to administer the morning of the procedure?
- A. Furosemide
- B. Acetaminophen
- C. Morphine sulfate
- D. Guaifenesin
Correct Answer: A
Rationale: Diuretics are contraindicated the morning of a test to avoid any interruptions for urination. Clients are also medicated to relieve a cough that may cause movement during the test so administration of guaifenesin is not contraindicated. Acetaminophen and morphine sulfate are not contraindicated the morning of the test.
A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?
- A. Heart rate of 72 beats/minute
- B. Respiratory rate of 20 breaths/minute
- C. Blood pressure 80/46 mm Hg
- D. Oxygen saturation 94%
Correct Answer: C
Rationale: The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minute is within normal range as well as the respiratory rate and oxygen saturation.
A client is brought to the emergency department via rescue squad with suspicion of cardiogenic pulmonary edema. What complication(s) should the nurse monitor for? Select all that apply.
- A. Nausea and vomiting
- B. Pulmonary embolism
- C. Cardiac arrhythmias
- D. Respiratory arrest
- E. Cardiac arrest
Correct Answer: C,D,E
Rationale: Pulmonary edema is fluid accumulation in the lungs, which interferes with gas exchange in the alveoli. It represents an acute emergency and is a frequent complication of left-sided heart failure. Cardiac arrhythmias and cardiac or respiratory arrest are associated complications. Nausea and vomiting are not complications but are symptoms of many disorders. The client is not at increased risk for the development of pulmonary embolism with pulmonary edema.
The nurse is caring for a client in the hospital with chronic heart failure that has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, he becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?
- A. Class I (Mild)
- B. Class II (Mild)
- C. Class III (Moderate)
- D. Class IV (Severe)
Correct Answer: C
Rationale: Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class I is ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.