Nokea
The nurse determines that the treatment of heart failure has been successful when the patient experiences
- A. Weight loss and diuresis
- B. Warm skin and less fatigue
- C. Clear lung sounds and decreased heart rate
- D. Absence of chest pain and improved LOC
Correct Answer: C
Rationale: Successful treatment of heart failure is indicated by an absence of symptoms of pulmonary edema and hypoxemia, such as clear lung sounds and a normal heart rate.
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Which chronic condition is characterized by abnormally thickened heart muscle, making it harder for the heart to pump blood efficiently?
- A. Hypertrophic cardiomyopathy
- B. Dilated cardiomyopathy
- C. Restrictive cardiomyopathy
- D. Ventricular hypertrophy
Correct Answer: A
Rationale: Rationale:
1. Hypertrophic cardiomyopathy (HCM) is characterized by thickening of the heart muscle.
2. The thickening reduces the heart's ability to pump blood efficiently.
3. This leads to symptoms like shortness of breath, chest pain, and fatigue.
4. HCM is a genetic condition that affects the heart's structure.
5. Dilated cardiomyopathy involves the heart becoming enlarged, not thickened.
6. Restrictive cardiomyopathy refers to stiffening of the heart muscle.
7. Ventricular hypertrophy is a general term for thickening of the heart's chambers, not the muscle itself.
Summary:
A is correct as HCM matches the description provided. B, C, and D do not align with the specific characteristics of abnormally thickened heart muscle seen in HCM.
A patient recently had a cardiac catheterization via right-radial approach and now has a compression device in place. The patient reports numbness and pain in the right hand. The cardiac-vascular nurse notes a diminished pulse, with a cool and cyanotic hand. The nurse:
- A. calls the physician.
- B. performs an Allen test.
- C. reduces the pressure on the puncture site.
- D. uses the Doppler ultrasound to assess for pulse signals.
Correct Answer: C
Rationale: Reducing pressure on the puncture site is necessary to restore blood flow to the hand.
What is most organ damage in hypertension related to?
- A. Increased fluid pressure exerted against organ tissue
- B. Atherosclerotic changes in vessels that supply the organs
- C. Erosion and thinning of blood vessels from constant pressure
- D. Increased hydrostatic pressure causing leakage of plasma into organ interstitial spaces
Correct Answer: B
Rationale: Atherosclerosis impairs organ perfusion.
In auscultating over a peripheral artery, what sound would suggest obstruction of the artery?
- A. Dullness
- B. Tympany
- C. Bruit
- D. Vibrations
Correct Answer: C
Rationale: A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often indicating partial obstruction.
The nurse is caring for a client on enalapril (Vasotec). What is the most important side effect to monitor?
- A. Cough
- B. Hyperkalemia
- C. Hypotension
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Cough. Enalapril is an ACE inhibitor that can cause a dry, persistent cough as a common side effect. It is important to monitor for this because it can indicate a potentially serious adverse reaction called angioedema. Hyperkalemia (B) is a possible side effect of enalapril but is typically not as urgent to monitor as cough. Hypotension (C) is a common side effect but is usually monitored during the initial dose titration. Dizziness (D) is a less common side effect and is often transient. Monitoring for cough is crucial to detect and manage any potential angioedema promptly.