Nokea
The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?
- A. There is excess fluid volume in the interstitial space in areas affected by gravity.
- B. There is excess fluid volume in the venous system of the lower extremities.
- C. There is excess fluid volume in the arterial system of the lower extremities.
- D. There is excess fluid volume in the hepatic system.
Correct Answer: A
Rationale: Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area. The other options are not descriptive of pitting edema.
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A client is admitted to the hospital with a diagnosis of heart failure, and the health care provider prescribes a BNP level. What results would indicate to the nurse that the client is in moderate heart failure?
- A. 120 pg/mL
- B. 400 pg/mL
- C. 780 pg/mL
- D. 980 pg/mL
Correct Answer: C
Rationale: The result of 780 pg/mL indicates that the client has moderate heart failure, 120 pg/mL indicates that the client has heart failure present, 400 pg/mL indicates that the client has mild heart failure, and 980 pg/mL indicates that the client is in severe heart failure.
The nurse is administering captopril to a client with a diagnosis of heart failure. What type of medication does the nurse infer the client is taking?
- A. An angiotensin converting enzyme inhibitor (ACE) inhibitor
- B. A thiazide diuretic
- C. An angiotensin receptor blocker (ARB)
- D. A calcium channel blocker
Correct Answer: A
Rationale: Captopril is an ACE inhibitor. Although the other medications may be used alone or in conjunction with other medications, the ACE inhibitor is a standard medication used in heart failure unless not tolerated by the client.
The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?
- A. Echocardiogram
- B. A pulmonary arteriography
- C. A chest radiograph
- D. Electrocardiogram
Correct Answer: A
Rationale: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm cor pulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart's conduction system.
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
- A. Intubation of the airway
- B. BP and pulse measurements every 15 to 30 minutes
- C. Insertion of a central venous catheter
- D. Hourly administration of a fluid bolus
Correct Answer: B
Rationale: Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
- A. Decreased urinary output
- B. Dyspnea on exertion
- C. Hypotension
- D. Tachycardia
Correct Answer: B
Rationale: Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia.