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A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?
- A. Premature ventricular contractions
- B. Atrial fibrillation
- C. Symptomatic bradycardia
- D. Sinus tachycardia
Correct Answer: B
Rationale: Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Premature ventricular contractions and bradycardia are not typically associated with valvular problems, and sinus tachycardia is linked to aortic regurgitation.
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A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?
- A. A 36-year-old woman with aortic stenosis
- B. A 42-year-old man with pulmonary hypertension
- C. A 50-year-old woman who smokes cigarettes daily
- D. A 70-year-old man who had a cerebral vascular accident
Correct Answer: A
Rationale: Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. Causes of left ventricular failure include aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.
A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client?
- A. Teach the client about dietary restrictions
- B. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor
- C. Encourage the client to take a baby aspirin each day
- D. Provide a plan for worsening symptoms
- E. Consult a social worker for additional resources
Correct Answer: A,B,D
Rationale: The Heart Failure Core Measure Set includes discharge instructions on diet, medications (like ACE inhibitors), and a plan for worsening symptoms. Aspirin is typically for myocardial infarction, not heart failure, and social worker consultation is not part of the Core Measure Set.
A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect?
- A. Hematocrit: 32.8%
- B. Serum sodium: 130 mEq/L
- C. Serum potassium: 5.8 mEq/L
- D. B-type natriuretic peptide: 1123 pg/mL
- E. Creatinine: 2.1 mg/dL
Correct Answer: A,B,C,D,E
Rationale: Heart failure can cause hemodilution (low hematocrit), hyponatremia (low sodium), hyperkalemia (high potassium), elevated B-type natriuretic peptide (indicating heart strain), and elevated creatinine (indicating renal dysfunction due to reduced cardiac output).
A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess?
- A. Pulmonary crackles
- B. Confusion, restlessness
- C. Pulmonary hypertension
- D. Dependent edema
- E. Cough that worsens at night
Correct Answer: A,B,E
Rationale: Left-sided heart failure leads to pulmonary congestion, causing pulmonary crackles, confusion, restlessness (due to hypoxia), and cough that worsens at night. Pulmonary hypertension and dependent edema are associated with right-sided heart failure.
A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching?
- A. Hold the next dose of Imdur
- B. Increase your intake of foods that are high in potassium
- C. Hold this medication if your pulse rate is below 90 beats per minute
- D. Do not take this medication within 1 hour of taking an antacid
Correct Answer: D
Rationale: Digoxin should not be taken within 1 hour of antacids, as antacids can decrease its absorption. Holding Imdur is irrelevant to digoxin therapy. Potassium intake needs monitoring, but hypokalemia (not high potassium) is a concern with digoxin. The pulse rate threshold for holding digoxin is typically below 60 beats per minute, not 90.