Nokea
A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?
- A. Assess for reduced urine output.
- B. Assess for reduced blood sodium levels.
- C. Assess for elevated blood potassium levels.
- D. Assess for elevated blood urea nitrogen levels.
Correct Answer: D
Rationale: Elevated blood urea nitrogen indicates impaired renal perfusion in a client with left-sided heart failure. Serum sodium levels may be elevated. Reduced urine output or elevated blood potassium levels do not indicate impaired renal perfusion in a client with left-sided heart failure.
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A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?
- A. The client says that he has been urinating less frequently at night.
- B. The client says he has been hungry in the evening.
- C. The client says his rings have become tight and are difficult to remove.
- D. The client says he is short of breath when ambulating.
Correct Answer: C
Rationale: Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.
The nurse is working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for the nurse to closely monitor an older adult receiving digitalis preparations for cardiac disorders?
- A. Older adults are at increased risk for toxicity.
- B. Older adults are at increased risk for cardiac arrests.
- C. Older adults are at increased risk for hyperthyroidism.
- D. Older adults are at increased risk for asthma.
Correct Answer: A
Rationale: Older adults receiving digitalis preparations are at increased risk for toxicity because of the decreased ability of the kidneys to excrete the drug due to age-related changes. The margin between a therapeutic and toxic effect of digitalis preparations is narrow. Using digitalis preparations does not increase the risk of cardiac arrests, hyperthyroidism, or asthma.
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?
- A. The development of chronic obstructive pulmonary disease (COPD)
- B. The development of left-sided heart failure
- C. The development of right-sided heart failure
- D. The development of cor pulmonale
Correct Answer: B
Rationale: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of/left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.
What disease process(es) contributes to chronic heart failure? Select all that apply.
- A. Tachyarrhythmias
- B. Valvular disease
- C. Pancreatic disease
- D. Renal failure
- E. Pulmonary insufficiency
Correct Answer: A,B,D
Rationale: Hypertension, tachyarrhythmias, valvular disease, cardiomyopathy, and renal failure can contribute to chronic heart failure. Pancreatic disease and pulmonary insufficiency do not contribute to chronic heart failure.
The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?
- A. There is excess fluid volume in the interstitial space in areas affected by gravity.
- B. There is excess fluid volume in the venous system of the lower extremities.
- C. There is excess fluid volume in the arterial system of the lower extremities.
- D. There is excess fluid volume in the hepatic system.
Correct Answer: A
Rationale: Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area. The other options are not descriptive of pitting edema.