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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.
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A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include for this client's discharge teaching?
- A. Use a soft-bristled toothbrush and avoid flossing
- B. Avoid large crowds and people who are sick
- C. Monitor your heart rate before taking the medication
- D. Take the medication with a high-fat meal
Correct Answer: B
Rationale: Cyclosporine causes immune suppression, leaving the client more vulnerable to infection. Avoiding large crowds and sick people reduces infection risk. The medication does not increase bleeding risk, affect heart rate, or require a high-fat meal.
A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
- A. Assess the client's respiratory status
- B. Draw blood for sodium electrolytes
- C. Administer intravenous furosemide (Lasix)
- D. Ask the client about current medications
Correct Answer: A
Rationale: Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications in heart failure exacerbation. Monitoring electrolytes, administering diuretics, and asking about medications are important but do not take priority over assessing respiratory status.
A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the priority nursing intervention?
- A. Oxygen saturation of 90%
- B. Dyspnea on exertion
- C. Mild systolic murmurs
- D. Upper extremity weakness
Correct Answer: B
Rationale: Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not directly indicate the progression of mitral valve stenosis.
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?
- A. Initiate oxygen therapy
- B. Hold the next dose of Imdur
- C. Instruct the client to drink water
- D. Administer PRN acetaminophen
Correct Answer: D
Rationale: The vasodilating effects of isosorbide mononitrate frequently cause headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The headache is not related to hypoxia or dehydration, so oxygen or water would not help. Holding the medication is not warranted.
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?
- A. Would you like to speak with a priest or chaplain?
- B. I will arrange for a psychiatrist to speak with you
- C. Do you want to come off the transplant list?
- D. Would you like information about advance directives?
Correct Answer: D
Rationale: This client is verbalizing a real concern about negative outcomes of the surgery. Providing information about advance directives allows the client to express their wishes and feel some control over their future. The other responses do not directly address the client's concerns or empower them.