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Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?
- A. Monitor liver function studies
- B. Monitor for hypotension
- C. Assess the patients vitamin D intake
- D. Assess the patient for hyperkalemia
Correct Answer: B
Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.
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The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action?
- A. Lay the patient flat
- B. Notify the family of the patients critical state
- C. Stay with the patient
- D. Update the physician
Correct Answer: C
Rationale: Because the patient has an unstable condition, the nurse must remain with the patient. The physician must be updated promptly, but the patient should not be left alone in order for this to happen. Supine positioning is unlikely to relieve dyspnea. The family should be informed, but this is not the priority action.
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.
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.
The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure?
- A. Jugular vein distention
- B. Right upper quadrant pain
- C. Bibasilar fine crackles
- D. Dependent edema
Correct Answer: C
Rationale: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock?
- A. The patient admitted with acute renal failure
- B. The patient admitted following an MI
- C. The patient admitted with malignant hypertension
- D. The patient admitted following a stroke
Correct Answer: B
Rationale: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While patients with acute renal failure are at risk for dysrhythmias and patients experiencing a stroke are at risk for thrombus formation, the patient admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.