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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).
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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 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 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.
A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis?
- A. A 36-year-old woman with systemic lupus erythematosus (SLE)
- B. A 52-year-old woman recovering from a myocardial infarction
- C. A 59-year-old woman recovering from cardiac surgery
- D. An 80-year-old man with a bacterial infection of the respiratory tract
- E. An 80-year-old woman with a stage III sacral ulcer
Correct Answer: A,B,D
Rationale: Acute pericarditis is associated with systemic connective tissue diseases like SLE, post-myocardial infarction (Dressler's syndrome), post-cardiac surgery inflammation, and bacterial infections. Stage III sacral ulcers do not increase the risk.
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, 'Why will I need to take anticoagulants for the rest of my life?' How should the nurse respond?
- A. The prosthetic valve requires thinner blood to function properly
- B. Blood clots form more easily in artificial replacement valves
- C. The vein taken from your leg reduces circulation in the leg
- D. The surgery left a lot of small clots in your heart and lungs
Correct Answer: B
Rationale: Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.