Nokea
The nurse is assessing a client diagnosed with left ventricular dysfunction. Which of the following would the nurse most likely assess? Select all that apply.
- A. Dyspnea
- B. Moist cough
- C. Restlessness
- D. Peripheral edema
- E. Neck vein distention
Correct Answer: A,B,C
Rationale: The symptoms of left ventricular dysfunction include dyspnea; moist cough; production of frothy, pink sputum; orthopnea; restlessness; and anxiety. Right-sided failure (right ventricular dysfunction) can be seen with fluid backup in the body such as distended neck veins, peripheral edema, and hepatic engorgement.
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Before administering a cardiotonic drug, the nurse would expect which of the following laboratory tests to be completed? Select all that apply.
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolyte levels
- E. Blood glucose
Correct Answer: A,B,C,D
Rationale: Liver function tests, renal function tests, complete blood count with the addition of serum electrolytes, and an electrocardiogram complete the lab workup prior to initiating therapy with a cardiotonic drug. It is not necessary to obtain serum blood glucose, but it might appear with other lab work that has been gathered.
A client comes to the clinic complaining of weakness and drowsiness. He states, 'I just get so tired sometimes that Lean't do what I want to do.' The client is receiving digoxin as part of the treatment for heart failure. Which nursing diagnosis would the nurse most likely identify?
- A. Risk for Injury
- B. Activity Intolerance
- C. Decreased Cardiac Output
- D. Imbalanced Nutrition: Less Than Body Requirements
Correct Answer: B
Rationale: Based on the client's statement and complaints, the nurse would most likely identify a nursing diagnosis of Activity Intolerance. Risk for Injury might be appropriate if the client complained of dizziness or if his complaints affected his ambulation. There is no evidence to support a nursing diagnosis of Decreased Cardiac Output or Imbalanced Nutrition.
A nursing instructor is conducting a class on heart failure and the events that occur. The instructor describes which of the following as a result of increases in neurohormonal activity that occur with heart failure? Select all that apply.
- A. Decreased secretion of catecholamines
- B. Remodeling of the cardiac muscle cells
- C. Hypertrophy of the heart
- D. Increased need for oxygen
- E. Cardiac necrosis
Correct Answer: B,C,D,E
Rationale: Increased catecholamines lead to increases in neurohormonal activity that cause remodeling of the cardiac muscle cells, leading to hypertrophy of the heart, increased need for oxygen, and cardiac necrosis, which worsen the heart failure.
A nurse is preparing to administer a prescribed cardiotonic to a client. The nurse understands that the drug is being administered to achieve which of the following? Select all that apply.
- A. Improved myocardial contractility
- B. Increased myocardial efficiency
- C. Increased blood pressure
- D. Increased peripheral edema
- E. Improved profusion to all body tissues
Correct Answer: A,B,E
Rationale: Cardiotonics are drugs used to increase the efficiency and improve the contraction of the heart muscle, which leads to improved blood flow to all tissues of the body.
After teaching a client about his prescribed cardiotonic drug therapy, the nurse determines that additional teaching is needed when the client states which of the following?
- A. I will take the drug at the same time each day.'
- B. I can crush the tablet and mix it with food.'
- C. I should call if my pulse rate is below 80 beats per minute.'
- D. I need to notify my doctor if I have blurred vision.'
Correct Answer: C
Rationale: The client should call the primary health care provider if his pulse rate is below 60 beats per minute or above 100 beats per minute. The client should take the drug at the same time each day, crush the tablet and mix with food, and notify the primary health care provider if blurred vision occurs.