Nokea
The nurse recognizes the echocardiogram report that shows an ejection factor of $42 \%$ as an indication of which situation?
- A. normal heart action.
- B. mild heart failure.
- C. moderate heart failure.
- D. severe heart failure.
Correct Answer: C
Rationale: An ejection fraction (cardiac output) of $42 \%$ indicates moderate heart failure.
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The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause which disorder?
- A. hypotension.
- B. thrombophlebitis.
- C. pulmonary emboli.
- D. heart failure.
Correct Answer: D
Rationale: Heart failure can result from rapid infusion of intravenous fluids in older adults.
The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention?
- A. Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.
- B. Place patient in side-lying position to reduce the symptoms of atrial fibrillation.
- C. Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema.
- D. Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock.
Correct Answer: C
Rationale: Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; and cold extremities. The legs in a dependent position will decrease venous return and ease the pulmonary edema.
The nurse is reinforcing instructions on a patient who will be taking digoxin. Which sign of digoxin toxicity should the nurse include?
- A. Ringing in the ears
- B. Bradycardia
- C. Headache
- D. Visual disturbance
- E. Hematuria
- F. Anorexia
Correct Answer: B,C,D,F
Rationale: Major signs of digoxin toxicity are bradycardia (HR <60), headache, visual disturbances, anorexia, as well as fatigue and arrhythmias.
Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer?
- A. Cool dry lower limb
- B. Darker, thick and toughened skin on medial surface of the leg
- C. Lack of hair and shiny appearance of the lower leg
- D. Lack of a pedal pulse
Correct Answer: B
Rationale: Signs of a venous disorder include darker, thick and toughened skin. Venous disorders can lead to a stasis ulcer. Cool hairless limbs with absent or weak pedal pulses are indicative of arterial insufficiency.
After an influenza-like illness, the patient reports chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of which disorder?
- A. congestive heart failure.
- B. heart block.
- C. aortic stenosis.
- D. infective endocarditis.
Correct Answer: D
Rationale: Collection of subjective data includes noting patient complaints of influenza-like symptoms with recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are indicative of infective endocarditis.