Nokea
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.
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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.
The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patients risk for heart failure (HF)?
- A. The patient takes Lasix (furosemide) 20 mg/day
- B. The patients potassium level is 4.7 mEq/L
- C. The patient is an African American man
- D. The patients age is greater than 65
Correct Answer: D
Rationale: HF is the most common reason for hospitalization of people older than 65 years of age and is the second most common reason for visits to a physicians office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for HF. The fact that the patient takes Lasix 20 mg/day does not indicate an increased risk for HF, although this drug is often used in the treatment of HF. The patient being an African American man does not indicate an increased risk for HF.
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.
The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms?
- A. Confusion and bradycardia
- B. Uncontrolled diuresis and tachycardia
- C. Numbness and tingling in the extremities
- D. Chest pain and shortness of breath
Correct Answer: A
Rationale: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.
The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patients diagnosis?
- A. Pulmonary edema
- B. Distended neck veins
- C. Dry cough
- D. Orthopnea
Correct Answer: B
Rationale: Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers do not apply.