Nokea
The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patients diagnosis?
- A. Pulmonary edema
- B. Distended neck veins
- C. Dry cough
- D. Orthopnea
Correct Answer: B
Rationale: Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers do not apply.
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The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem?
- A. Pericarditis
- B. Cardiomyopathy
- C. Pulmonary edema
- D. Right ventricular hypertrophy
Correct Answer: C
Rationale: As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the patients hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.
A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurses nutritional teaching plan has been effective?
- A. I will have a ham and cheese sandwich for lunch
- B. I will have a baked potato with broiled chicken for dinner
- C. I will have a tossed salad with cheese and croutons for lunch
- D. I will have chicken noodle soup with crackers and an apple for lunch
Correct Answer: B
Rationale: The patients choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.
The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action?
- A. Lay the patient flat
- B. Notify the family of the patients critical state
- C. Stay with the patient
- D. Update the physician
Correct Answer: C
Rationale: Because the patient has an unstable condition, the nurse must remain with the patient. The physician must be updated promptly, but the patient should not be left alone in order for this to happen. Supine positioning is unlikely to relieve dyspnea. The family should be informed, but this is not the priority action.
The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock?
- A. The patient admitted with acute renal failure
- B. The patient admitted following an MI
- C. The patient admitted with malignant hypertension
- D. The patient admitted following a stroke
Correct Answer: B
Rationale: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While patients with acute renal failure are at risk for dysrhythmias and patients experiencing a stroke are at risk for thrombus formation, the patient admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.
The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurses rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm?
- A. Pulseless electrical activity (PEA)
- B. Ventricular fibrillation
- C. Ventricular tachycardia
- D. Asystole
Correct Answer: D
Rationale: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.