Nokea
The nurses comprehensive assessment of a patient who has HF includes evaluation of the patients hepatojugular reflux. What action should the nurse perform during this assessment?
- A. Elevate the patients head to 90 degrees
- B. Press the right upper abdomen
- C. Press above the patients symphysis pubis
- D. Lay the patient flat in bed
Correct Answer: B
Rationale: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.
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A cardiac patients resistance to left ventricular filling has caused blood to back up into the patients circulatory system. What health problem is likely to result?
- A. Acute pulmonary edema
- B. Right-sided HF
- C. Right ventricular hypertrophy
- D. Left-sided HF
Correct Answer: A
Rationale: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided HF, left-sided HF, and right ventricular hypertrophy do not directly occur.
The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum?
- A. Skin turgor
- B. Potassium level
- C. White blood cell count
- D. Peripheral pulses
Correct Answer: B
Rationale: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.
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 patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patients health history creates a heightened risk of intracardiac thrombi?
- A. Atrial fibrillation
- B. Infective endocarditis
- C. Recurrent pneumonia
- D. Recent surgery
Correct Answer: A
Rationale: Intracardiac thrombi are especially common in patients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.
The nurse is providing patient education prior to a patients discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist?
- A. Know how to recognize and prevent orthostatic hypotension
- B. Weigh yourself weekly at a consistent time of day
- C. Measure everything you eat and drink until otherwise instructed
- D. Limit physical activity to only those tasks that are absolutely necessary
Correct Answer: A
Rationale: Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.