Nokea
The nurse instructs the client with heart failure to check weight at the same time each day using the same scale. When should the client contact the health care provider?
- A. If the weight gain is more than 3 lb in 1 week.
- B. If the weight gain is more than 4 lb in 1 month.
- C. If the weight gain is more than 2 lb in 24 hours.
- D. If the weight gain is more than 1 lb in 48 hours.
Correct Answer: C
Rationale: Clients should check weight at the same time each day using the same scale and should consult a health care provider if the weight gain is more than 2 pounds in 24 hours. The other options are not correct since there is a variance with weight on a daily basis.
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A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?
- A. The development of chronic obstructive pulmonary disease (COPD)
- B. The development of left-sided heart failure
- C. The development of right-sided heart failure
- D. The development of cor pulmonale
Correct Answer: B
Rationale: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of/left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.
A client diagnosed with heart failure has been admitted to the ICU prior to invasive treatment. What treatment could be considered curative for this client?
- A. Cardiomyoplasty
- B. External pacemaker placement
- C. Surgical ventricular restoration
- D. Ventricular assist device
Correct Answer: C
Rationale: A procedure known as surgical ventricular restoration (SVR) decreases the size of the heart to a near normal size and shape by removing dysfunctional heart muscle that does not contract properly. Once the adynamic (nonfunctioning) area is removed, the ventricle is repaired with a patch. In the cases that were studied, 91% were free of congestive heart failure after surgery with an ejection fraction that increased from 30% to 40%. A cardiomyoplasty, placement of an external pacemaker, or a ventricular assist device are not considered curative for heart failure.
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.
A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?
- A. Assess for reduced urine output.
- B. Assess for reduced blood sodium levels.
- C. Assess for elevated blood potassium levels.
- D. Assess for elevated blood urea nitrogen levels.
Correct Answer: D
Rationale: Elevated blood urea nitrogen indicates impaired renal perfusion in a client with left-sided heart failure. Serum sodium levels may be elevated. Reduced urine output or elevated blood potassium levels do not indicate impaired renal perfusion in a client with left-sided heart failure.
The student nurse is caring for a client with heart failure. Diuretics have been prescribed. What method might be used with a debilitated client to help the nurse evaluate the client's response to diuretics?
- A. Using mechanical ventilation
- B. Using a urinary catheter
- C. Using a pulmonary artery catheter
- D. Using a biventricular pacemaker
Correct Answer: B
Rationale: To evaluate response to diuretics, a urinary catheter is used. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. A biventricular pacemaker is used to sustain life.