Nokea
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.
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The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?
- A. Administer the medication and inform the charge nurse about the rate.
- B. Withhold the medication and notify the health care provider of the heart rate.
- C. Administer atropine to speed the heart rate and then administer the digoxin.
- D. Administer the medications and then notify the health care provider.
Correct Answer: B
Rationale: Digitalis drugs are withheld if the heart rate is less than 60 or more than 120 beats/minute until a health care provider is consulted. The other choices would have the nurse administer the drug, which would not be the standard of practice.
The nurse instructs the client with heart failure to check weight at the same time each day using the same scale. When should the client contact the health care provider?
- A. If the weight gain is more than 3 lb in 1 week.
- B. If the weight gain is more than 4 lb in 1 month.
- C. If the weight gain is more than 2 lb in 24 hours.
- D. If the weight gain is more than 1 lb in 48 hours.
Correct Answer: C
Rationale: Clients should check weight at the same time each day using the same scale and should consult a health care provider if the weight gain is more than 2 pounds in 24 hours. The other options are not correct since there is a variance with weight on a daily basis.
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, 'I cannot catch my breath.' How would the nurse document this finding?
- A. Can't walk without becoming short of breath
- B. Has paroxysmal nocturnal dyspnea when walking
- C. Has orthopnea when walking
- D. Experiences exertional dyspnea when walking 3 feet; states, I cannot catch my breath.
Correct Answer: D
Rationale: Exertional dyspnea is the effort at breathing when active. Answer A is vague and does not give a more detailed explanation for documentation purposes. Orthopnea is the inability to breathe unless sitting upright, and paroxysmal nocturnal dyspnea is being awakened by breathlessness.
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.
A client in the hospital informs the nurse he 'feels like his heart is racing and can't catch his breath.' What does the nurse understand occurs as a result of a tachyarrhythmia?
- A. It causes a loss of elasticity in the myocardium.
- B. It reduces ventricular ejection volume.
- C. It increases afterload.
- D. It increases preload.
Correct Answer: B
Rationale: Reducing ventricular ejection volume because diastole, during which the ventricle fills with blood (preload), is shortened as a result of a tachyarrhythmia. Causing a loss of elasticity in the muscle is a result of cardiomyopathy. Afterload is decreased not increased.