Nokea
When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?
- A. A diastolic blood pressure that is lower during exhalation
- B. A diastolic blood pressure that is higher during inhalation
- C. A systolic blood pressure that is higher during exhalation
- D. A systolic blood pressure that is lower during inhalation
Correct Answer: D
Rationale: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.
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The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting?
- A. Monitor her blood pressure daily
- B. Assess her radial pulses daily
- C. Monitor her weight daily
- D. Monitor her bowel movements
Correct Answer: C
Rationale: To assess fluid balance at home, the patient should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.
The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient?
- A. A beta-adrenergic blocker
- B. An antiplatelet aggregator
- C. A calcium channel blocker
- D. A nonsteroidal anti-inflammatory drug (NSAID)
Correct Answer: A
Rationale: Several medications are routinely prescribed for systolic HF, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.
The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem?
- A. Pericarditis
- B. Cardiomyopathy
- C. Pulmonary edema
- D. Right ventricular hypertrophy
Correct Answer: C
Rationale: As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the patients hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.
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 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.