Nokea
The nurse is caring for a client with right-sided heart failure. When assessing the respiratory rate of this client, what is an indication that the client is having difficulty breathing?
- A. Not using the abdominal muscles during breathing
- B. Using accessory muscles during respiration
- C. Barely palpable, thready pulse volume
- D. Combination of noisy and quiet respiration
Correct Answer: B
Rationale: When assessing the respiratory rate of a client with a cardiovascular disorder, the nurse observes the character of the respirations, noting whether the client's breathing is easy, labored, or dyspneic; deep or shallow; and noisy or quiet. The use of accessory muscles such as neck or abdominal muscles during respiration is an indication that the client is having difficulty breathing. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable.
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The nurse is assessing a client who has dyspnea and considering the process of gas exchange. Which structural characteristic of capillaries best enables gas exchange at the cellular level?
- A. Capillaries are one cell-layer thick.
- B. Capillaries form a complex network
- C. Capillaries transport blood back to the heart.
- D. Capillaries are elastic structures.
Correct Answer: A
Rationale: Capillaries are one cell-layer thick and in direct contact with the cells of all tissues. This allows ease of gas exchange. Capillaries do form a complex network; however, it is the one cell structure that facilitates gas exchange. Venules and veins transport blood back to the heart. Arteries are elastic.
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected?
- A. Whistling
- B. Rhonchi
- C. Crackles
- D. Coarseness
Correct Answer: C
Rationale: When the left side of the heart is pumping inefficiently, blood backs up into the pulmonary veins and lung tissue. Auscultation reveals a crackling sound. Wheezes and gurgles may also be heard.
The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage?
- A. Fluoroscopy
- B. Nuclear cardiology
- C. Serum blood work
- D. Chest radiography
Correct Answer: B
Rationale: Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting tissue damage.
The nurse provides care for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which clinical finding should the nurse anticipate relating to the infarction location?
- A. Jugular vein distention
- B. Irregular heart rate
- C. Peripheral edema
- D. Fever
Correct Answer: B
Rationale: The posterior wall of the right atrium is the location of the sinoatrial node (SA node), which is the pacemaker of the heart. Damage to this location may result in an irregular heart rate due to a disturbance of electrical pulse initiation. Jugular vein distension and peripheral edema are anticipated for the client who is experiencing heart failure, not myocardial infarction (MI). Although fever can increase the client's heart rate, this is not an expected finding with an MI.
One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response?
- A. Distention of the jugular vein
- B. Effort to lie down to breathe
- C. Right-sided heart failure
- D. Blood congestion in neck veins
Correct Answer: C
Rationale: If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may inspect the distention of external jugular vein.