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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.
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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.
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.
After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate correct understanding of the teaching related to nutritional intake?
- A. I should limit my fluid intake to 2 liters per day
- B. I need to avoid adding salt to my foods
- C. I should eat foods high in potassium, like bananas
- D. I must avoid foods high in vitamin K
- E. I will check food labels for sodium content
Correct Answer: A,B,C,E
Rationale: Clients with CHF should limit fluid intake (typically to 2 liters/day), avoid adding salt, eat potassium-rich foods (especially if on diuretics), and check sodium content. Avoiding vitamin K is specific to clients on warfarin, not a general CHF requirement.
A nurse assesses a client for signs of infective endocarditis. Which clinical manifestations should the nurse expect?
- A. Weight gain
- B. Night sweats
- C. Cardiac murmur
- D. Abdominal bloating
- E. Osler nodes
Correct Answer: B,C,E
Rationale: Clinical manifestations of infective endocarditis include night sweats, cardiac murmur, and Osler nodes. Weight gain and abdominal bloating are not typical; the latter is associated with heart transplant rejection.
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.