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The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first?
- A. Check for a carotid pulse
- B. Apply supplemental oxygen
- C. Give two full breaths
- D. Gently shake and shout, Are you OK?
Correct Answer: D
Rationale: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.
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The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patients care?
- A. Improve functional status
- B. Prevent endocarditis
- C. Extend survival
- D. Limit physical activity
- E. Relieve patient symptoms
Correct Answer: A,C,E
Rationale: The overall goals of management of HF are to relieve the patients symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.
A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient?
- A. In a high Fowlers position
- B. On the left side-lying position
- C. In a flat, supine position
- D. In the Trendelenburg position
Correct Answer: A
Rationale: Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying does not promote circulation.
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.
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.
The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics?
- A. Avoid drinking fluids for 2 hours after taking the diuretic
- B. Take the diuretic in the morning to avoid interfering with sleep
- C. Avoid taking the medication within 2 hours consuming dairy products
- D. Take the diuretic only on days when experiencing shortness of breath
Correct Answer: B
Rationale: Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patients nighttime rest. Discussing the timing of medication administration is especially important for elderly patients who may have urinary urgency or incontinence. The nurse would not teach the patient about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated.