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Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following?
- A. Perform at least 100 chest compressions per minute
- B. Pause to allow a colleague to provide a breath every 10 compressions
- C. Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes
- D. Perform high-quality chest compressions as rapidly as possible
Correct Answer: A
Rationale: During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute. This rate is the resuscitators goal; the aim is not to give compressions as rapidly as possible. Compressions are not stopped after 10 compressions to allow for a breath or for full vital signs monitoring.
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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 planning the care of a patient with HF. The nurse should identify what overall goals of this patients care?
- A. Improve functional status
- B. Prevent endocarditis
- C. Extend survival
- D. Limit physical activity
- E. Relieve patient symptoms
Correct Answer: A,C,E
Rationale: The overall goals of management of HF are to relieve the patients symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.
The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF?
- A. An S3 heart sound
- B. Pleural friction rub
- C. Faint breath sounds
- D. A heart murmur
Correct Answer: A
Rationale: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of HF.
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.
Diagnostic imaging reveals that the quantity of fluid in a clients pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication?
- A. Pulmonary edema
- B. Pericardiocentesis
- C. Cardiac tamponade
- D. Pericarditis
Correct Answer: C
Rationale: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiological process.