Nokea
The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patients risk for heart failure (HF)?
- A. The patient takes Lasix (furosemide) 20 mg/day
- B. The patients potassium level is 4.7 mEq/L
- C. The patient is an African American man
- D. The patients age is greater than 65
Correct Answer: D
Rationale: HF is the most common reason for hospitalization of people older than 65 years of age and is the second most common reason for visits to a physicians office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for HF. The fact that the patient takes Lasix 20 mg/day does not indicate an increased risk for HF, although this drug is often used in the treatment of HF. The patient being an African American man does not indicate an increased risk for HF.
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The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs?
- A. Loop diuretic and antiplatelet aggregator
- B. Loop diuretic and calcium channel blocker
- C. Combination of hydralazine and isosorbide dinitrate
- D. Combination of digoxin and normal saline
Correct Answer: C
Rationale: A combination of hydralazine and isosorbide dinitrate may be an alternative for patients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.
A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurses best action?
- A. Rapidly assess the patients cardiopulmonary status
- B. Arrange for an ECG
- C. Increase the height of the patients bed
- D. Manage the patients anxiety
Correct Answer: A
Rationale: Patient management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the patient, even though each of these actions may be appropriate and necessary.
A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela?
- A. Stroke
- B. Myocardial infarction (MI)
- C. Hemorrhage
- D. Peripheral edema
Correct Answer: A
Rationale: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.
The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patients sensorium and LOC. Why is the assessment of the patients sensorium and LOC important in patients with HF?
- A. HF ultimately affects oxygen transportation to the brain
- B. Patients with HF are susceptible to overstimulation of the sympathetic nervous system
- C. Decreased LOC causes an exacerbation of the signs and symptoms of HF
- D. The most significant adverse effect of medications used for HF treatment is altered LOC
Correct Answer: A
Rationale: As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in patients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular.
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.