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A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?
- A. Right-sided heart failure
- B. Acute pulmonary edema
- C. Pneumonia
- D. Cardiogenic shock
Correct Answer: B
Rationale: Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.
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A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela?
- A. Stroke
- B. Myocardial infarction (MI)
- C. Hemorrhage
- D. Peripheral edema
Correct Answer: A
Rationale: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.
The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure?
- A. Jugular vein distention
- B. Right upper quadrant pain
- C. Bibasilar fine crackles
- D. Dependent edema
Correct Answer: C
Rationale: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?
- A. A diastolic blood pressure that is lower during exhalation
- B. A diastolic blood pressure that is higher during inhalation
- C. A systolic blood pressure that is higher during exhalation
- D. A systolic blood pressure that is lower during inhalation
Correct Answer: D
Rationale: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.
A patient with a diagnosis of HF is started on a beta-blocker. What is the nurses priority role during gradual increases in the patients dose?
- A. Educating the patient that symptom relief may not occur for several weeks
- B. Stressing that symptom relief may take up to 4 months to occur
- C. Making adjustments to each days dose based on the blood pressure trends
- D. Educating the patient about the potential changes in LOC that may result from the drug
Correct Answer: A
Rationale: An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC.
A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient?
- A. In a high Fowlers position
- B. On the left side-lying position
- C. In a flat, supine position
- D. In the Trendelenburg position
Correct Answer: A
Rationale: Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying does not promote circulation.