Nokea
A patient with heart failure has tachypnea, severe dyspnea, and a SpO2 of 84%. The nurse identifies a nursing diagnosis of impaired gas exchange related to increased preload and mechanical failure. An appropriate nursing intervention for this diagnosis is
- A. Assist the patient to cough and deep breath every 2 hours
- B. Assess intake and output every 8 hours and weigh daily
- C. Encourage to alternate rest and activity to reduce cardiac workload
- D. Place the patient in a high Fowler's position with the legs horizontal
Correct Answer: D
Rationale: A high fowler's position increases the thoracic capacity, improving ventilation, and sitting with the legs horizontal will decrease venous return.
You may also like to solve these questions
Which condition is characterized by fluid collection in the lungs, making it difficult to breathe?
- A. Pulmonary edema
- B. Pleurisy
- C. Pleural effusion
- D. Pneumothorax
Correct Answer: A
Rationale: Pulmonary edema is the correct answer because it is characterized by fluid accumulation in the lungs, leading to difficulty in breathing. This condition is often a result of heart failure, where the heart is unable to pump blood effectively, causing fluid to leak into the lungs. It can also be caused by lung infections or exposure to toxins.
Pleurisy (B) is inflammation of the pleura, the lining around the lungs, leading to chest pain exacerbated by breathing. Pleural effusion (C) is fluid accumulation in the pleural space around the lungs, not within the lungs themselves. Pneumothorax (D) is characterized by air accumulation in the pleural space, causing lung collapse, but not fluid collection in the lungs.
High SVR is most likely to cause damage to which organ?
- A. Brain
- B. Heart
- C. Retina
- D. Kidney
Correct Answer: D
Rationale: Elevated SVR strains renal arterioles, leading to kidney damage.
In cases of myocardial infarction leading to shock, which medication is appropriate to counteract shock?
- A. Atropine
- B. Dopamine
- C. Digoxin
- D. Adenosine
Correct Answer: B
Rationale: The correct answer is B: Dopamine. In myocardial infarction leading to shock, dopamine is appropriate due to its positive inotropic effects, increasing cardiac output and blood pressure. Atropine is not indicated for shock in this context. Digoxin may be contraindicated in acute myocardial infarction. Adenosine is not used in managing shock.
What is a condition where the walls of the arteries in the lungs become thickened and stiff, leading to increased blood pressure in the pulmonary arteries?
- A. Pulmonary hypertension
- B. Pulmonary fibrosis
- C. Pulmonary embolism
- D. Pulmonary edema
Correct Answer: A
Rationale: The correct answer is A: Pulmonary hypertension. Pulmonary hypertension refers to the condition where the walls of the arteries in the lungs become thickened and stiff, leading to increased blood pressure in the pulmonary arteries. This results in the heart having to work harder to pump blood through the lungs, causing potential damage to the heart and lungs over time.
B: Pulmonary fibrosis is a condition characterized by scarring of lung tissue, not thickening and stiffening of artery walls.
C: Pulmonary embolism is a blockage in one of the pulmonary arteries in your lungs, usually caused by a blood clot. It does not involve thickening and stiffening of artery walls.
D: Pulmonary edema is a condition where fluid builds up in the lungs, causing difficulty in breathing. It is not related to thickened and stiffened artery walls.
What is a surgical procedure to redirect blood flow around a blocked or narrowed artery, often involving the use of a graft from another part of the body?
- A. Coronary artery bypass graft (CABG)
- B. Valve replacement
- C. Aneurysm repair
- D. Atherectomy
Correct Answer: A
Rationale: The correct answer is A: Coronary artery bypass graft (CABG). This procedure is used to redirect blood flow around a blocked or narrowed artery by creating a bypass using a graft from another part of the body. Step 1: The blocked or narrowed artery is identified through diagnostic tests. Step 2: A graft, often taken from the chest, leg, or arm, is used to create a new pathway for blood to flow around the blockage. Step 3: This helps improve blood flow to the heart muscle, relieving symptoms such as chest pain and reducing the risk of a heart attack. Summary: B (Valve replacement) involves replacing a damaged heart valve, C (Aneurysm repair) deals with treating a weakened area in a blood vessel, and D (Atherectomy) is a procedure to remove plaque from arteries, none of which match the description provided.