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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.
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The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.
- A. Facilitate the presence of friends and family whenever possible
- B. Teach the patient about the harmful effects of anxiety on cardiac function
- C. Provide supplemental oxygen, as needed
- D. Provide validation of the patients expressions of anxiety
- E. Administer benzodiazepines two to three times daily
Correct Answer: A,C,D
Rationale: The nurse should empathically validate the patients sensations of anxiety. The presence of friends and family are frequently beneficial and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some patients, but alternative methods of relief should be prioritized. As well, medications are administered on a PRN basis. Teaching the patient about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.
A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment?
- A. Blood pressure
- B. Level of consciousness (LOC)
- C. Assessment for nausea
- D. Oxygen saturation
Correct Answer: A
Rationale: Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.
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 triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first?
- A. Check for a carotid pulse
- B. Apply supplemental oxygen
- C. Give two full breaths
- D. Gently shake and shout, Are you OK?
Correct Answer: D
Rationale: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.
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.