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A client with heart failure reports not having had a bowel movement in 2 days. Why would it be important for the nurse to obtain a prescription for a stool softener?
- A. Straining engages the Valsalva maneuver, which can cause dangerous effects.
- B. The client should not develop hemorrhoids.
- C. The client can develop a rectal fissure, which will increase pain levels.
- D. The client should have a bowel movement every day to avoid development of an intestinal obstruction.
Correct Answer: A
Rationale: Avoid activities that engage the Valsalva maneuver, such as straining with bowel elimination or using the arms to pull and reposition oneself. The Valsalva maneuver increases intrathoracic pressure, reduces right atrial filling, triggers tachycardia, and increases blood pressure. The client's discomfort would be increased if hemorrhoids or a rectal fissure developed but would not engage the Valsalva maneuver. It is not necessary for the client to have a bowel movement on a daily basis.
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A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
- A. Intubation of the airway
- B. BP and pulse measurements every 15 to 30 minutes
- C. Insertion of a central venous catheter
- D. Hourly administration of a fluid bolus
Correct Answer: B
Rationale: Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.
A client is admitted to the hospital with a diagnosis of heart failure, and the health care provider prescribes a BNP level. What results would indicate to the nurse that the client is in moderate heart failure?
- A. 120 pg/mL
- B. 400 pg/mL
- C. 780 pg/mL
- D. 980 pg/mL
Correct Answer: C
Rationale: The result of 780 pg/mL indicates that the client has moderate heart failure, 120 pg/mL indicates that the client has heart failure present, 400 pg/mL indicates that the client has mild heart failure, and 980 pg/mL indicates that the client is in severe heart failure.
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.
The student nurse is caring for a client with heart failure. Diuretics have been prescribed. What method might be used with a debilitated client to help the nurse evaluate the client's response to diuretics?
- A. Using mechanical ventilation
- B. Using a urinary catheter
- C. Using a pulmonary artery catheter
- D. Using a biventricular pacemaker
Correct Answer: B
Rationale: To evaluate response to diuretics, a urinary catheter is used. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. A biventricular pacemaker is used to sustain life.
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.