Chapter 34 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 34

Question 1

Type: MCSA

A 60-year-old male patient is being seen in the clinic for an annual physical. Which assessment finding would the nurse discuss with the patient in regard to preventing future heart failure?

1. High hemoglobin A1C

2. Blood pressure 119/78

3. Father-in-law died from heart disease a year ago

4. Male

Correct Answer: 1

Rationale 1: Elevated hemoglobin A1C indicates possible diabetes. Diabetes is a risk factor for development of heart failure.

Rationale 2: Hypertension is a modifiable risk factor, but a blood pressure of 119/78 is not hypertensive.

Rationale 3: An in-laws death from cardiac disease is unrelated to the patients risk factors.

Rationale 4: Being male is a risk factor but is not modifiable.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-1

Question 2

Type: MCSA

A patient with heart failure has orthopnea, tachycardia, fatigue, and activity intolerance. How would the nurse explain the presence of these findings?

1. You are not coping with your bodys changing health.

2. Your bodys protective mechanisms are malfunctioning.

3. You have not been following instructions on caring for yourself.

4. Your body is trying to maintain an adequate blood pressure and oxygen supply.

Correct Answer: 4

Rationale 1: These findings are not related to the patients coping mechanisms.

Rationale 2: The patients inherent compensatory mechanisms are not malfunctioning, but instead continue to attempt to maintain homeostasis.

Rationale 3: These symptoms are not caused by the patients noncompliance with instructions.

Rationale 4: The patients compensatory mechanisms attempt initially to compensate for the falling blood pressure and oxygen levels. At the outset, these mechanisms are able to keep up with the bodys demands. However, over the long term, they create bigger problems.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-3

Question 3

Type: MCSA

The nurse assesses that a patient is more anxious than usual. The patient states, I dont understand how I can still be alive when my

heart has failed. Which nursing response is indicated?

1. Heart failure is a common problem in the United States. Many people have it. They all have problems such as yours.

2. Heart failure doesnt mean your heart has quit, just that it no longer is as efficient as it once was.

3. You seem upset. Would you like for me to call the health care provider to explain this to you?

4. Heart failure is pretty complicated. It means the heart is failing to work.

Correct Answer: 2

Rationale 1: Stating that the problem is common does not help the patient understand the condition.

Rationale 2: Helping the patient understand that the heart is still functioning may help alleviate concerns about imminent death.

Rationale 3: Contacting the health care provider is not necessary; the nurse should know how to respond to this question.

Rationale 4: This response does not provide the patient with enough information.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-7

Question 4

Type: MCSA

Which nursing diagnosis would the nurse add to the care plan of a patient diagnosed with acute systolic heart failure?

1. Disturbed Body Image

2. Imbalanced Nutrition: More than Body Requirements

3. Excess Fluid Volume

4. Ineffective Airway Clearance

Correct Answer: 3

Rationale 1: Disturbed Body Image is not a likely nursing diagnosis for this patient.

Rationale 2: If there is an imbalance in nutrition, it is more likely to be less than body requirements.

Rationale 3: Acute systolic heart failure is typically characterized by Excess Fluid Volume.

Rationale 4: Ineffective Airway Clearance is not applicable, as these patients do not have issues with clearing the airway as much as with impaired gas exchange.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 34-6

Question 5

Type: MCSA

Which assessment finding would the nurse expect when caring for a patient with right-sided heart failure?

1. Has trouble concentrating on the conversation

2. Is dyspneic with activity

3. Has to sleep on three or four pillows at night

4. Consumes 5% of meals and complains of nausea

Correct Answer: 4

Rationale 1: Poor concentration and mentation can be related to left-ventricular heart failure.

Rationale 2: Activity intolerance is more likely related to left-ventricular failure.

Rationale 3: Orthopnea is more likely related to left-sided heart failure.

Rationale 4: Poor appetite and complaints of nausea and vomiting correspond to right-sided heart failure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-3

Question 6

Type: MCSA

A patient diagnosed with heart failure asks the nurse if the problem is in the right or left side of the heart. Which symptom would indicate to the nurse that left-sided heart failure is occurring?

1. Elevated neck veins

2. Respiration of 36 per minute

3. Dependent edema

4. Right upper quadrant pain

Correct Answer: 2

Rationale 1: Elevated neck veins are a symptom of right-sided heart failure.

Rationale 2: The patient with left-sided heart failure has pulmonary involvement and is therefore tachypneic.

Rationale 3: Dependent edema is a symptom of right-sided heart failure.

Rationale 4: The liver may become engorged with right-sided heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 34-3

Question 7

Type: MCSA

A patient with left-sided heart failure is admitted to the unit. Which assessment is a priority upon admission?

1. Abdominal assessment

2. Neurological status

3. Presence of peripheral edema

4. Airway and oxygenation status

Correct Answer: 4

Rationale 1: Abdominal assessment will be included in the admission assessment, but problems with this area are more common in right-sided failure.

Rationale 2: Neurological assessment is important and will reflect cerebral perfusion, but it is not the highest priority assessment listed.

Rationale 3: Extremities will be assessed for edema, but this finding is found more frequently with right-sided failure.

Rationale 4: The patient with left-sided failure will exhibit symptoms of a respiratory nature. The priority assessment for this patient would be the airway and oxygenation status.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-4

Question 8

Type: MCSA

The nurse is assessing a patient who has been admitted with heart failure. The nurse anticipates which lab test to be ordered to determine the severity of the diagnosis?

1. Troponin

2. Lipid panel

3. CBC

4. BNP

Correct Answer: 4

Rationale 1: Troponin levels may indicate the etiology of the heart failure.

Rationale 2: A lipid panel may give information about the etiology of the heart failure.

Rationale 3: A CBC will likely be ordered and will provide valuable information about the patients overall condition, but not specifically about severity of heart failure. Another test is more specific.

Rationale 4: BNP, renal function, and liver function studies may provide an indication of the severity of the heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-5

Question 9

Type: MCSA

A patient is admitted with heart failure. The nurse establishes a nursing diagnosis of Decreased Cardiac Output related to ventricular dysfunction. Which parameter would the nurse evaluate as indicating that cardiac output is sufficient?

1. BP 100/48

2. Daily weight same as the day before

3. CI 1.8 L/min/m2

4. PAOP 8 mmHg

Correct Answer: 4

Rationale 1: This blood pressure measurement is low and could indicate low cardiac output.

Rationale 2: Because fluid volume overload is an underlying cause of decreased cardiac output, the goal is for the patient to lose water weight each day.

Rationale 3: Cardiac index should be between 2.0 and 3.2 L/min/m2.

Rationale 4: PAOP is a hemodynamic parameter used to monitor cardiac output. This is a normal PAOP.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 34-6

Question 10

Type: MCSA

A patient is admitted to the hospital with a provisional diagnosis of heart failure. Which laboratory finding would the nurse evaluate as ruling out that diagnosis?

1. BNP 50 pg/mL

2. Normal ECG

3. Sodium 148 mEq/L

4. Hemoglobin 10 g/dl

Correct Answer: 1

Rationale 1: A BNP within normal limits rules out heart failure.

Rationale 2: Normal ECG results would not rule out heart failure, which may be occurring for reasons other than electrical disturbances of the heart or myocardial infarction.

Rationale 3: This sodium level is slightly high, but does not indicate or rule out heart failure.

Rationale 4: This hemoglobin result is slightly low but does not rule in or rule out heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-6

Question 11

Type: MCSA

A patient with heart failure is sent home on lisinopril (Zestril). Which medication information should the nurse provide?

1. Lisinopril is a beta-blocker drug that will increase the pumping ability of the heart.

2. Lisinopril is an angiotensin II receptor blocker (ARB) that will lower the heart rate.

3. Lisinopril is a calcium channel blocker that could make heart failure worse.

4. Lisinopril is an ACE inhibitor that lowers blood pressure.

Correct Answer: 4

Rationale 1: Lisinopril is not a beta-blocker and does not affect the pumping ability of the heart.

Rationale 2: Lisinopril is not an ARB. ARB medications are used in the treatment of heart failure. They do not lower the heart rate.

Rationale 3: Lisinopril is not a calcium channel blocker and would not worsen heart failure symptoms.

Rationale 4: Lisinopril is an ACE inhibitor medication. ACE inhibitors act by reducing systemic vascular resistance, thereby lowering blood pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-7

Question 12

Type: MCSA

A patient diagnosed with heart failure is preparing for discharge. The patient asks the nurse if a special diet is necessary. How should the nurse respond?

1. A special diet is important for you. Let me tell you about it in detail.

2. I am glad you asked. The health care provider will be discussing the diet with you.

3. The pharmacist will be talking with the physician. They will let the dietitian know what is best for you.

4. I will be reviewing your discharge plans with you, but I would also like to ask the dietitian to come visit with you to help finalize your diet.

Correct Answer: 4

Rationale 1: The nurse can discuss generalities about the required diet but is not the best person to provide detailed instruction.

Rationale 2: While the physician is important in the health care team, the most appropriate person to discuss the details of the diet is not the physician.

Rationale 3: The pharmacist will have information about any potential drugfood interactions; however, dietary teaching is not the pharmacists primary role. Another health care professional better fills that role.

Rationale 4: The dietician is the most qualified member of the interdisciplinary team to give the patient specific guidance regarding diet.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-6

Question 13

Type: MCSA

The nurse uses the acronym MAWDS to teach a patient about self-care management for heart failure. Which instruction would this method contain?

1. You should return to the clinic for monthly follow-up.

2. Check your weight daily.

3. Elevate the feet for twenty minutes twice daily.

4. Avoid large crowds.

Correct Answer: 2

Rationale 1: Follow-up is scheduled on an individual basis and may vary, depending on symptoms.

Rationale 2: MAWDS stands for medication, activity, weight, diet, and symptoms. Part of the self-management plan is checking daily weight and knowing when to report weight changes.

Rationale 3: Elevation of the feet may or may not be indicated for individual patients.

Rationale 4: Avoiding large crowds is not a typical instruction for a heart failure patient and is not part of the MAWDS regimen.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-7

Question 14

Type: MCSA

Which statement by a patient with heart failure would indicate to the nurse that the patient does not understand the discharge instructions?

1. I will increase my activity a little every day.

2. I will contact the health care provider if I begin gaining weight.

3. I will eat a low-sodium diet.

4. I will pick up my new medications in a few days when I get paid.

Correct Answer: 4

Rationale 1: A slow increase in activity is a reasonable goal and meets the activity requirement for this disease process.

Rationale 2: The patient should understand that changes in weight indicate changes in fluid volume status.

Rationale 3: Low sodium intake (less than 1.5 grams per day) is necessary for patients with heart failure.

Rationale 4: It is important that the patient take the medication each and every day. Waiting for a few days to pick up the medication will not be effective.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 34-7

Question 15

Type: MCSA

A diabetic patient received instructions from the nurse on ways to minimize further damage to the heart from heart failure. Which patient statement reflects the most important strategy toward this goal?

1. I will weigh myself every day.

2. I will follow a diet.

3. I will take a daily walk.

4. I will keep my hemoglobin A1C less than 6.4.

Correct Answer: 4

Rationale 1: Weighing daily is beneficial but is not the most important strategy.

Rationale 2: Following an appropriate diet is beneficial but is not the most important strategy.

Rationale 3: Daily exercise is beneficial but is not the most important strategy.

Rationale 4: Aggressively treating diabetes, targeting the hemoglobin A1C, and preventing target organ damage will limit the risk of developing coronary artery disease and systolic dysfunction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 34-7

Question 16

Type: MCSA

The nurse is providing medication instruction to a patient who has both hypertension and heart failure. The nurse would expect this patient to be prescribed which drug?

1. Cardiac glycoside

2. ACE inhibitor

3. Antidysrhythmic

4. Anticoagulants

Correct Answer: 2

Rationale 1: Cardiac glycosides (digoxin) are not a first-line option for a patient with both hypertension and heart failure, although they can be used for heart failure alone.

Rationale 2: The patient who has both hypertension and heart failure can expect to be taking ACE inhibitors, which treat both diseases.

Rationale 3: Antidysrhythmics are not used to treat heart failure or hypertension unless there are other underlying comorbidities.

Rationale 4: Anticoagulants are not used to treat heart failure or hypertension unless there are other underlying comorbidities.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-8

Question 17

Type: MCSA

A patient is in hospice with a diagnosis of end-stage heart failure. How would the nurse explain the primary treatment goal for this patient?

1. Provide significant pain medications.

2. Provide comfort and reduce any distressing respiratory symptoms.

3. Keep the patient out of the hospital.

4. Provide information to the family.

Correct Answer: 2

Rationale 1: Pain medications may be provided in the course of the overall plan but this is not the primary treatment goal.

Rationale 2: The goals of care are to provide comfort measures and reduce or eliminate any primary symptoms that may be distressing, such as respiratory distress.

Rationale 3: Keeping the patient out of the hospital would be a goal if the patient desires to stay at home. This is not the overall focus of care.

Rationale 4: Communication with the family and patient is important but is not the overall focus of care.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-9

Question 18

Type: MCSA

A patient with heart failure is facing the end of life. Which intervention would the nurse prioritize with this patient?

1. Have the health care provider discuss end-of-life topics with the patient.

2. Tell the patient that the family should be the primary source of support, but that nursing staff will be glad to substitute if necessary.

3. Be as honest as possible about the progression of the disease and the support needed.

4. Reassure the patient that death will be painless.

Correct Answer: 3

Rationale 1: The health care provider will be involved in end-of-life discussions, but as a patient advocate the nurse can certainly discuss end-of-life options with the patient.

Rationale 2: Telling the patient that the nursing staff will substitute for family implies that the family is not fulfilling its role.

Rationale 3: The heart failure patient who is nearing the end of life will need honest discussions regarding the progression of the disease and the support needed and available.

Rationale 4: The nurse cannot promise a painless death for this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-9

Question 19

Type: MCSA

The nurse is assessing a patient with chronic heart failure. Which abnormal chest sound would the nurse most likely auscultate?

1. Systolic murmur

2. Friction rub

3. Harsh vesicular lung sounds

4. Crackles

Correct Answer: 4

Rationale 1: A systolic murmur is not expected in a patient with chronic heart failure.

Rationale 2: Friction rub is not expected in a patient with chronic heart failure.

Rationale 3: Harsh vesicular lung sounds are not expected in a patient with chronic heart failure.

Rationale 4: Fluid accumulates in the alveolar spaces in left-sided heart failure. This fluid causes the sound of crackles at the end of inspiration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-4

Question 20

Type: MCSA

The nurse is caring for a patient who has chronic left-sided heart failure. Which statement would the nurse expect in the physicians written report following cardiac catheterization?

1. Pressures in the left ventricle and atrium are increased.

2. Pressures in the left ventricle and atrium are equal.

3. Pressures in the right ventricle and atrium match the left ventricular pressures.

4. Pressures in the right ventricle exceed those in the left ventricle.

Correct Answer: 1

Rationale 1: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole and the chamber pressure rises due to the added blood volume.

Rationale 2: Pressures in the atria and ventricles are not equal. Ventricular pressures are higher.

Rationale 3: This patient is in left-sided heart failure, so pressure is higher in the left side of the heart.

Rationale 4: Pressures are higher on the left side.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 34-4

Question 21

Type: MCSA

The nurse caring for a patient with heart failure would expect which assessment findings?

1. S1, S2, and flat neck veins

2. S3 and distended neck veins

3. S2 loudest and followed by S1

4. S4 and flat neck veins

Correct Answer: 2

Rationale 1: S1 and S2 are normal heart sounds; flat neck veins are considered a normal finding.

Rationale 2: The abnormal S3 sound is reflective of the hearts attempts to fill an already distended ventricle, and the neck veins distend because of the increased venous pressure.

Rationale 3: S1 always precedes S2.

Rationale 4: S4 (gallop) may be present, but neck veins would be distended.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-4

Question 22

Type: MCSA

Which statement by the patient would the nurse evaluate as significant to the diagnosis of congestive heart failure (CHF)?

1. I break out in a cold sweat when I eat a large meal.

2. I am sleepy after I eat lunch every day.

3. I have to prop myself up on three pillows to sleep at night, otherwise I cant breathe.

4. I feel better after I exercise.

Correct Answer: 3

Rationale 1: Diaphoresis after eating is a significant finding but is not typically associated with CHF.

Rationale 2: Afternoon sleepiness is caused by a number of factors and does not imply the presence of CHF.

Rationale 3: Needing to prop oneself up with pillows in order to breathe describes orthopnea, which is consistent with CHF. CHF produces a volume excess, congestion in the lungs, and dyspnea when the patient attempts to lie down.

Rationale 4: Persons with CHF are generally exercise intolerant.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-4

Question 23

Type: MCSA

An elderly patient was recently discharged to home after treatment for chronic heart failure. The patient experiences a pulse rate increase from 80 beats per minute (bpm) to 102 bpm when walking from the kitchen to the utility room to do laundry. What is an appropriate nursing action for the home health nurse?

1. Encourage the patient to complete tasks such as laundry early in the morning before fatigue is an issue.

2. Recommend that the patient ignore the pulse rate and become more active to build stamina.

3. Encourage the patient to rest for 30 minutes between completing each load of laundry.

4. Encourage the patient to sit and rest in the utility room and whenever the patient feels the pulse rate increase.

Correct Answer: 4

Rationale 1: Doing all the laundry in the morning will not help in this particular situation.

Rationale 2: The patient should not ignore this signal that the heart is working too hard.

Rationale 3: The issue is with walking to the utility room, not with the actual work associated with doing the laundry.

Rationale 4: The increase in pulse rate indicates that activity is not being tolerated. Rest should help bring the heart rate down to the pre-activity level.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-6

Question 24

Type: MCMA

The nurse assesses for which sign of decreased cardiac output and tissue perfusion in a patient with heart failure?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Reduced mental alertness

2. Increased urine output

3. Abdominal distention

4. Strong peripheral pulses

5. Cachexia

Correct Answer: 1,5

Rationale 1: A change in mentation is a common sign of decreased cardiac output and tissue perfusion.

Rationale 2: Urine output would decrease.

Rationale 3: Abdominal distention is a sign of right-sided failure, which is a problem with venous return, not cardiac output or tissue perfusion.

Rationale 4: Pulses would weaken.

Rationale 5: Patients with severe pulmonary diseases often cannot take in enough calories to meet increased demands. This fact, along with neurohormonal changes, results in cachexia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-3

Question 25

Type: MCSA

The nurse is assessing a patient who is demonstrating dyspnea, orthopnea, cyanosis, clammy skin, crackles, and a productive cough with pink, frothy sputum. The nurse realizes that the patient likely has which condition?

1. Chronic heart failure

2. Pulmonary edema

3. Endocarditis

4. Angina

Correct Answer: 2

Rationale 1: Not all patients with chronic heart failure have pink, frothy sputum. The presence of this symptom differentiates pulmonary edema from chronic heart failure.

Rationale 2: Dyspnea, orthopnea, cyanosis, clammy skin, productive cough with pink frothy sputum, and crackles are signs and symptoms of pulmonary edema, which is considered a medical emergency.

Rationale 3: Endocarditis would manifest with pain and possibly fever.

Rationale 4: Angina is chest pain.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-4

Question 26

Type: MCSA

What is the priority nursing action the nurse would implement for a patient who is admitted with pulmonary edema?

1. Insert a peripheral intravenous catheter.

2. Seek a prescription to medicate the patient for comfort.

3. Monitor the blood glucose level.

4. Place a pulse oximeter and administer oxygen.

Correct Answer: 4

Rationale 1: Inserting an IV would be the second action, but often, if more than one caregiver is present, this action can be done simultaneously with the first.

Rationale 2: Medication would not be given until the ABCs have been addressed.

Rationale 3: The blood glucose level is not related to pulmonary edema.

Rationale 4: Because this is a medical emergency, priority nursing actions focus on maintaining the airway and improving oxygenation, then breathing and circulation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-6

Question 27

Type: MCMA

The nurse realizes that a patient is experiencing paroxysmal nocturnal dyspnea (PND) when which symptoms are reported?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Symptoms occurring at night

2. Pulmonary congestion while lying down

3. Improving cardiac reserve

4. Voiding more than once at night

5. Attacks occurring suddenly

Correct Answer: 1,2,5

Rationale 1: PND is a condition in which the patient is awakened at night and frightened by acute shortness of breath. It occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night, causing pulmonary congestion.

Rationale 2: PND is a condition in which the patient is awakened by acute shortness of breath, usually after several hours of sleep. It occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night, causing pulmonary congestion.

Rationale 3: Chronic heart failure is characterized by decreasing cardiac reserve and dependent edema that worsens as the day progresses.

Rationale 4: Nocturia is the term for this condition, and it is not associated with PND.

Rationale 5: Attacks of PND occur suddenly.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-4

Question 28

Type: MCMA

The nurse, caring for an elderly patient, realizes that aging adults are at higher risk for development of heart failure because of which changes?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Impaired diastolic filling

2. Increased cardiac reserve

3. Increased maximal heart rate

4. Reduced ventricular compliance

5. High responsiveness to sympathetic nervous system stimulation

Correct Answer: 1,4

Rationale 1: Impaired diastolic filling occurs due to decreased ventricular compliance.

Rationale 2: With aging, cardiac function is less responsive to increased stress because cardiac reserve decreases.

Rationale 3: Maximal heart rate is reduced.

Rationale 4: Ventricular compliance tends to diminish with aging.

Rationale 5: The heart becomes less responsive to sympathetic nervous system stimulation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-1

Question 29

Type: MCMA

A 68-year-old patient is prescribed furosemide (Lasix) for treatment of heart failure. The patient is diabetic, hypertensive, and had hip replacement surgery last year. Which laboratory results should be closely monitored due to the addition of this drug?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Potassium

2. Glucose

3. Magnesium

4. Bleeding times

5. Thyroid function test

Correct Answer: 1,2

Rationale 1: Potassium levels should be closely monitored. Both hyperkalemia and hypokalemia can occur, depending on other medications being taken.

Rationale 2: Glucose levels can be affected by some loop diuretics.

Rationale 3: Magnesium levels are not altered by this drug.

Rationale 4: Bleeding times are not affected by furosemide.

Rationale 5: Thyroid function is not affected by furosemide.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 34-8

Question 30

Type: MCMA

A patient is being started on enalapril (Vasotec). The nurse would teach the patient to be alert for which adverse effects?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increased thirst

2. Dizziness

3. Cough

4. Sore throat

5. Constipation

Correct Answer: 2,3

Rationale 1: Increased thirst is not an adverse effect of enalapril.

Rationale 2: The use of enalapril can result in dizziness related to a decrease in blood pressure.

Rationale 3: Cough is a common adverse effect of ACE inhibitors and may prompt a change to a different medication.

Rationale 4: Sore throat is not an expected adverse effect of enalapril.

Rationale 5: Constipation is not an expected adverse effect of enalapril.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-6

Question 31

Type: MCMA

A nurse is considering employment in a heart failure management clinic. The nurse would expect to work primarily with patients having which underlying disease processes?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hypertension

2. Renal failure

3. Coronary artery disease (CAD)

4. Dilated cardiomyopathy

5. Pneumonia

Correct Answer: 1,3,4

Rationale 1: Hypertension is a primary etiology of heart failure.

Rationale 2: Heart failure can be caused by a number of disease processes, including renal failure, but this is not a primary causative factor.

Rationale 3: CAD is a major etiology of heart failure.

Rationale 4: Dilated cardiomyopathy is a primary etiology of heart failure.

Rationale 5: Patients with pneumonia can develop heart failure, but this disease is not a primary causative factor.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 34-1

Question 32

Type: MCMA

A patient is diagnosed with diastolic dysfunction leading to heart failure. The nurse is likely to identify which comorbidities in this patients assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has diabetes.

2. The patient has cardiomyopathy.

3. The patient is obese.

4. The patient has frequent premature ventricular contractions.

5. The patient is hypotensive.

Correct Answer: 1,2,3

Rationale 1: Diabetes is one of the most common characteristics of those diagnosed with diastolic disorder.

Rationale 2: One of the causes of diastolic disorder is cardiomyopathy.

Rationale 3: Obesity is common among those most often diagnosed with diastolic disorder.

Rationale 4: Atrial fibrillation is the dysrhythmia most often associated with diastolic disorder.

Rationale 5: Hypertension is more commonly associated with diastolic disorder.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-2

Question 33

Type: MCMA

Which explanation of diastolic dysfunction by the nurse would help clarify the physiological process for the patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Your heart does not relax as well or as quickly as it should between beats.

2. You have a stiff, noncompliant heart.

3. The muscle of your heart does not stretch as well as it needs to.

4. Your irregular heartbeat keeps your heart from working as efficiently as it should.

5. Your obesity has caused your heart muscle to be infiltrated with fat.

Correct Answer: 1,3,4

Rationale 1: Prolonged relaxation is a physiological change associated with diastolic dysfunction.

Rationale 2: The patient is not likely to understand this statement. Education should be provided at a level the patient can understand.

Rationale 3: Stiffness of the muscle is a component of diastolic dysfunction.

Rationale 4: Atrial fibrillation is commonly associated with diastolic dysfunction.

Rationale 5: This statement is not correct and implies blame on the patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 34-2

Question 34

Type: MCMA

A patient admitted with heart failure has had arterial blood gases drawn. Which findings would the nurse expect?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Low PO2

2. pH under 7.35

3. pH over 7.45

4. Normal values

5. High PO2

Correct Answer: 1,2,3

Rationale 1: Low oxygen blood levels are commonly found in patients in heart failure.

Rationale 2: Acidosis is commonly found in patients in heart failure.

Rationale 3: Patients in heart failure can present with alkalosis.

Rationale 4: Normal values are unlikely if the patient has presented for treatment.

Rationale 5: High PO2 levels are not commonly noted when patients are in heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 34-5

Question 35

Type: MCMA

A 79-year-old patient is in a heart failure clinic. Which findings would the nurse evaluate as indicating a poor prognosis for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. New York Heart Association (NYHA) class I assignment

2. Low ejection fraction

3. Low sodium levels

4. Sinus bradycardia without ectopy

5. Low exercise capacity

Correct Answer: 2,3,5

Rationale 1: The higher NYHA classes reflect a higher risk of mortality.

Rationale 2: A low ejection fraction indicates the heart is failing, as less blood is ejected by the heart and more blood stays in the heart. This is an ominous finding.

Rationale 3: Hyponatremia is associated with a poor prognosis in older adults.

Rationale 4: Ventricular dysrhythmias and conduction system delays are associated with a poor prognosis.

Rationale 5: A diminishing ability to tolerate activity is an indicator of worsening heart failure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 34-9

 

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