Chapter 7 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 7

Question 1

Type: MCSA

When teaching a patient with heart failure about ventricular remodeling, the nurse should recognize that additional teaching is needed if the patient makes which statement? Remodeling:

1. Leads to progressive worsening of heart function.

2. Can be described as an enlargement of the pumping chamber.

3. Occurs with an increase in blood pressure and results in weight gain.

4. Develops primarily because the heart is pumping harder.

Correct Answer: 4

Rationale 1: This is a correct statement about remodeling and no additional teaching is required.

Rationale 2: This is a correct statement about remodeling and no additional teaching is required.

Rationale 3: The long-term activation of sympathetic nervous system and the renin-angiotensin-aldosterone system can lead to an increase in blood pressure and weight gain. This is a correct statement about remodeling and no additional teaching is required.

Rationale 4: The heart is not pumping harder but rather the contractility or elasticity of the left ventricle is decreased or stiffer in nature. This statement indicates more teaching is required.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7-1: Explain the pathophysiologic and neurohormonal mechanisms of heart failure.

Question 2

Type: MCMA

The nurse is reviewing a patients medical history. Which factors in the history most likely contributed to the patients development of 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. Hypertension

2. Diabetes mellitus

3. Drinking one or two alcoholic drinks daily

4. Being overweight

5. Ischemic heart disease

Correct Answer: 1,5

Rationale 1: Hypertension is identified as an etiology of heart failure.

Rationale 2: Diabetes is not a known cause of heart failure.

Rationale 3: Drinking moderately is not a known cause of heart failure.

Rationale 4: Being overweight is not a direct contributing factor to the development of heart failure.

Rationale 5: Ischemia to the heart is a known cause of heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-1: Explain the pathophysiologic and neurohormonal mechanisms of heart failure.

Question 3

Type: MCSA

The nurse is assessing a patient for heart failure (HF). Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure?

1. Orthopnea, peripheral edema, crackles

2. Dizziness, syncope, palpitations

3. Pallor and/or cyanosis of extremities

4. PAWP of 12 and CVP of 6

Correct Answer: 1

Rationale 1: These symptoms reflect decreasing perfusion and accumulation of fluid in the pulmonary system, which is not being effectively circulated by a failing heart.

Rationale 2: Dizziness, syncope, and palpitations are symptoms of end-organ hypoperfusion, not fluid overload. These symptoms represent later symptoms of hypoxia from less blood being carried to distal organs, especially the brain and the heart. The pulmonary backup of fluid occurs before the hypoxia.

Rationale 3: Pallor and/or cyanosis are seen in end-organ hypoperfusion, not a fluid overload situation. Distal areas do not receive adequate arterial blood flow and the tissue becomes hypoxic quickly, which causes the pallor or cyanosis from venous stasis.

Rationale 4: Pulmonary arterial wedge pressure and central venous pressure would increase with fluid overload because the pressure of additional fluids must be overcome to circulate the blood.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7-3: Differentiate between the manifestations of left- and right-sided heart failure.

Question 4

Type: MCSA

Which assessment finding indicates that a patients heart failure (HF) is worsening?

1. An increase in O2 saturation to greater than 90%

2. A decrease in heart rate to 66 bpm

3. The onset of atrial fibrillation

4. Louder S1 and S2 heart sounds

Correct Answer: 3

Rationale 1: Oxygenation saturations will decline to less than 90% and not increase to more than 90%. Declining O2 saturation levels reflect deteriorating pulmonary status from a buildup of fluids with pulmonary edema.

Rationale 2: Tachycardia increases to compensate for the decreasing O2 levels by trying to circulate what cells are present, but at the same time increases the O2 demand by increased cardiac functioning.

Rationale 3: As heart failure continues to progress, less oxygenation occurs all over the body, especially the myocardium, which is sensitive to the hypoxia and will result in dysrhythmias such as ventricular ectopy or atrial fibrillation.

Rationale 4: The S1 and S2 sounds remain the same.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-3: Differentiate between the manifestations of left- and right-sided heart failure.

Question 5

Type: MCSA

A patient is very short of breath. Which finding should cause the nurse to be concerned that the shortness of breath might be due to heart failure?

1. An echocardiogram that reflected increased right ventricular wall thickening

2. A B-type natriuretic peptide (BNP) of 300 pg/mL

3. A left ventricular ejection fraction (VEF) of 50%

4. A serum sodium of 135

Correct Answer: 2

Rationale 1: Echocardiogram would reflect left ventricular hypertrophy, not right ventricular enlargement.

Rationale 2: A BNP greater than 100 pg/mL suggests heart failure as a cause of dyspnea.

Rationale 3: Many patients with heart failure will have a reduced ejection fraction of less than 40%.

Rationale 4: Hyponatremia is commonly found in the patient with heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-4: Describe the hemodynamic findings indicative of heart failure

Question 6

Type: MCSA

Which finding would support the diagnosis of heart failure (HF)?

1. RA/CVP of 8 mm Hg

2. PAWP of 20 mm Hg

3. Cardiac index of 3

4. Peripheral vasodilation reflected by normalizing capillary refill times

Correct Answer: 2

Rationale 1: The RA/CVP are increased with rising pressures to push through the inadequate pumping that occurs with heart failure from systemic venous pressure elevations from ascites and peripheral edema.

Rationale 2: With heart failure the backup of fluid from inadequate pumping results in increased PAWP because the heart has to pump harder to push through the rising capillary pressures on the venous side from peripheral edema and ascites.

Rationale 3: Cardiac output is decreased with heart failure because the preload volume continues to rise with a less efficient pump to remove the blood.

Rationale 4: Peripheral vasoconstriction occurs and capillary refills are sluggish and delayed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-4: Describe the hemodynamic findings indicative of heart failure.

Question 7

Type: MCSA

After teaching a patient with heart failure about beta blocking agents, the nurse recognizes that additional teaching is needed when the patient states, While taking the medication, I will:

1. Weigh myself every day.

2. Check my blood sugar regularly.

3. Notify my health care provider if I become increasingly short of breath.

4. Monitor myself daily for an increased heart rate and blood pressure.

Correct Answer: 4

Rationale 1: This is a correct statement that does not require additional instruction.

Rationale 2: This is a correct statement that does not require additional instruction.

Rationale 3: This is a correct statement that does not require additional instruction.

Rationale 4: Beta blocking agents will decrease the heart rate and blood pressure. This statement indicates that additional teaching is needed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7-5: Explain collaborative management of the patient with heart failure.

Question 8

Type: MCSA

The nurse should explain to a patient in heart failure that an aldosterone antagonist works by:

1. Reducing sodium and water retention

2. Filtering potassium out with the water in the renal tubules

3. Promoting the excretion of the urinary waste products urea and creatinine

4. Retaining calcium to improve the condition of blood vessels in the glomeruli

Correct Answer: 1

Rationale 1: An aldosterone antagonist removes water through the excretion of sodium and water through the renal tubules.

Rationale 2: This is not the mechanism of an aldosterone antagonist.

Rationale 3: This is not the mechanism of an aldosterone antagonist.

Rationale 4: This is not the mechanism of an aldosterone antagonist.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-5: Explain collaborative management of the patient with heart failure.

Question 9

Type: MCSA

What would the nurse not expect to find in a patient who was experiencing acute decompensated heart failure with pulmonary edema?

1. Dyspnea at rest, peripheral edema

2. Hypertension, bradycardia

3. Increased coughing, crackles

4. Decreased O2 saturation, increased PAWP

Correct Answer: 2

Rationale 1: These are symptoms of acute decompensated heart failure with pulmonary edema.

Rationale 2: Hypertension and bradycardia are not symptoms of pulmonary edema.

Rationale 3: Fluid can be heard on chest auscultation and coughing will increase when attempting to try to clear the passageways of the backed-up fluid.

Rationale 4: Due to fluid in the capillary beds, less perfusion and ventilation occur, which lead to hypoxia and increased pressures in the pulmonary artery.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-6: Describe the patient with acute decompensated heart failure.

Question 10

Type: MCSA

A patient in heart failure is to be started on an infusion of dobutamine (Dobutrex). What is most important for the nurse to assess before starting the infusion? The patients:

1. Breath sounds

2. Blood pressure

3. Level of consciousness

4. Urine output

Correct Answer: 2

Rationale 1: Breath sounds are not the most important for the nurse to assess before starting this infusion.

Rationale 2: Prior to initiation, before each titration, and at the peak action of dobutamine, the nurse must assess blood pressure, heart rate, respiratory rate, and oxygen saturation. Frequent assessment of these parameters should continue throughout the infusion period.

Rationale 3: Level of consciousness is not the most important for the nurse to assess before starting this infusion.

Rationale 4: Urine output is not the most important for the nurse to assess before starting this infusion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7: Describe collaborative management strategies appropriate for the patient with acute decompensated heart failure.

Question 11

Type: MCSA

A patient in heart failure is being given a first dose of lisinopril (Prinivil) 10 mg PO. Which finding would cause the nurse to question the administration of the first dose?

1. Heart rate 92 beats per minute

2. Blood pressure 100/72

3. Potassium 5.7 mEq/dL

4. Urine output 35 mL/hr

Correct Answer: 3

Rationale 1: This would not cause the nurse to question the first dose of the medication.

Rationale 2: This would not cause the nurse to question the first dose of the medication.

Rationale 3: Ace inhibitors increase the serum potassium and a further increase from 5.7 could be problematic so the nurse should question the administration of this medication.

Rationale 4: This would not cause the nurse to question the first dose of the medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7-5: Explain collaborative management of the patient with heart failure.

Question 12

Type: MCMA

An 82-year-old patient is readmitted for heart failure (HF) 1 week after being discharged for the same diagnosis. Which findings most likely contributed to the patients readmission?

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

Standard Text: Select all that apply.

1. Not knowing how or when to take medications

2. Not prescribed appropriate medications, including ACE inhibitors and beta blockers

3. No record of body weight since discharge

4. Not filling prescribed medications

5. Received the pneumococcal immunization during the last hospitalization

Correct Answer: 1,2,3,4

Rationale 1: Some studies indicate that older patients with heart failure have poor knowledge of appropriate medication management.

Rationale 2: There is evidence that a significant number of older adults with heart failure do not receive evidence-based, AHA-recommended care including angiotensin-converting enzymes (ACE) inhibitors and beta blockers.

Rationale 3: Patient records indicate that daily weights are not consistently obtained.

Rationale 4: Pharmacy records indicate that prescriptions are not promptly refilled.

Rationale 5: Pneumococcal immunization is recommended and would not contribute to a readmission for the diagnosis of heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-5: Explain collaborative management of the patient with heart failure.

Question 13

Type: MCSA

The nurse is caring for a patient with acute decompensated heart failure (HF) receiving BiPAP. While caring for this patient, the nurses priority will be to:

1. Monitor the expiratory time to be sure that it always exceeds the inspiratory time.

2. Ensure that the mask does not fit too tightly on the patients face to prevent skin breakdown.

3. Prepare for endotracheal intubation because BiPAP is used primarily to buy time for intubation.

4. Assess the patient for the development of gastric distention, nausea, and vomiting.

Correct Answer: 4

Rationale 1: This is not something that the nurse needs to monitor for the patient receiving BiPAP.

Rationale 2: Although important, this is not a priority for the nurse when caring for the patient receiving BiPAP.

Rationale 3: BiPAP provides end-expiratory pressure, further decreasing the work of breathing. It is not used primarily to buy time for intubation.

Rationale 4: The nurse must assess the patient for complications resulting from this delivery method to include gastric distention, nausea, vomiting, and aspiration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-7: Describe collaborative management strategies appropriate for the patient with acute decompensated heart failure.

Question 14

Type: MCSA

What is the most appropriate position for a patient in pulmonary edema with a blood pressure of 194/92?

1. Sitting upright with legs dependent

2. Dorsal recumbent

3. Head of the bed elevated 60 degrees

4. Torso flat, feet elevated

Correct Answer: 1

Rationale 1: A patient with a blood pressure of 194/92 is able to sit upright. Sitting upright with legs dependent allows the patient to breathe more comfortably and prevents fluid from accumulating as easily in the lungs.

Rationale 2: This position would not aid with respiratory effort.

Rationale 3: Fluid still may accumulate in the lungs with the patient in this position.

Rationale 4: This position will encourage the accumulation of fluid in the patients lungs and increase dyspnea.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-7: Describe collaborative management strategies appropriate for the patient with acute decompensated heart failure.

Question 15

Type: MCSA

The nurse notes that the QRS duration of a patient with a biventricular pacemaker is widening? What does this most likely indicate?

1. Worsening of the patients underlying cardiomyopathy

2. Loss of ventricular capture

3. Loss of ventricular synchronization

4. Battery failure

Correct Answer: 3

Rationale 1: This is not an indication that the patients underlying condition is getting worse.

Rationale 2: This does not indicate loss of ventricular capture.

Rationale 3: Widening of the QRS duration from the baseline may indicate a loss of ventricular synchronization.

Rationale 4: This does not indicate battery failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7: Describe collaborative management strategies appropriate for the patient with acute decompensated heart failure.

Question 16

Type: MCSA

A patient with heart failure has a decreasing cardiac output. The nurse will expect compensatory mechanisms to be activated in order to:

1. Decrease the heart rate

2. Maintain perfusion to vital organs

3. Cause arteriolar vasodilation in nonessential vascular beds

4. Inhibit the release of aldosterone

Correct Answer: 2

Rationale 1: Compensatory mechanisms will increase the heart rate.

Rationale 2: As the heart function fails and cardiac output decreases, compensatory mechanisms are activated to maintain perfusion to the vital organs.

Rationale 3: Compensatory mechanisms will cause arteriolar vasoconstriction in nonessential vascular beds.

Rationale 4: Compensatory mechanisms will lead to the release of aldosterone.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-1: Explain the pathophysiologic and neurohormonal mechanisms of heart failure.

Question 17

Type: MCMA

While caring for a patient in heart failure, the nurse assesses an elevated blood pressure and significant peripheral edema. These symptoms are caused by the renin-angiotensin-aldosterone system which:

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

Standard Text: Select all that apply.

1. Releases angiotensin II

2. Releases aldosterone

3. Decreases cardiac output

4. Decreases heart rate

5. Causes arteriolar vasodilation

Correct Answer: 1,2

Rationale 1: Activation of the renin-angiotensin-aldosterone system increases vasoconstriction through the release of angiotensin II, a potent vasoconstrictor.

Rationale 2: Activation of the renin-angiotensin-aldosterone system increases water and sodium reabsorption through the release of aldosterone.

Rationale 3: Activation of the renin-angiotensin-aldosterone system does not decrease cardiac output.

Rationale 4: Activation of the renin-angiotensin-aldosterone system does not decrease heart rate.

Rationale 5: Activation of the renin-angiotensin-aldosterone system does not cause arteriolar vasodilation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-1: Explain the pathophysiologic and neurohormonal mechanisms of heart failure.

Question 18

Type: MCMA

A patient is diagnosed with left-sided heart failure. When describing this disease process to the patient, the nurse will include:

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

Standard Text: Select all that apply.

1. Pumping action of the heart is impaired.

2. Filling action of the heart is impaired.

3. Blood backs up in the left side of the heart.

4. Extra fluid can build up in the lungs.

5. Extra fluid can build up in the lower extremities.

Correct Answer: 1,2,3,4

Rationale 1: In left-sided heart failure, the pumping action or systolic action of the left ventricle is impaired.

Rationale 2: In left-sided heart failure, the ability of the left ventricle to fill or diastolic action of the left ventricle is impaired.

Rationale 3: In left-sided heart failure, blood backs up from the left ventricle to the left atrium.

Rationale 4: In left-sided heart failure, fluid eventually builds up in the lungs.

Rationale 5: Extra fluid does not build up in the lower extremities in left-sided heart failure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-2: Compare and contrast systolic and diastolic dysfunction.

Question 19

Type: MCMA

A patient is diagnosed with diastolic heart failure. The nurse realizes this type of heart failure is caused by:

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

Standard Text: Select all that apply.

1. Normal sized but hypertrophied left ventricle

2. Blood backing up into the right atrium

3. Loss of ventricular diastolic relaxation

4. Blood backing up into the left atrium

5. Excessive fluid in the lower extremities

Correct Answer: 1,2,3

Rationale 1: Diastolic dysfunction occurs when the ventricle is normal sized by hypertrophied.

Rationale 2: In diastolic heart failure, blood backs up from the right ventricle to the right atrium.

Rationale 3: In diastolic heart failure there is a loss of left ventricular diastolic relaxation.

Rationale 4: Blood does not back up into the left atrium in diastolic heart failure.

Rationale 5: Excessive fluid in the lower extremities does not cause diastolic heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-2: Compare and contrast systolic and diastolic dysfunction.

Question 20

Type: MCMA

Which finding would cause the nurse to suspect a patient with heart failure was experiencing end organ hypoperfusion?

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

Standard Text: Select all that apply.

1. Confusion

2. Dropping blood pressure

3. Urine output 15 mL per hour

4. Heart rate 124

5. Peripheral edema

Correct Answer: 1,2,3,4

Rationale 1: Confusion is a manifestation of end organ hypoperfusion.

Rationale 2: Hypotension is a manifestation of end organ hypoperfusion.

Rationale 3: Decreased urinary output is a manifestation of end organ hypoperfusion.

Rationale 4: Tachycardia is a manifestation of end organ hypoperfusion.

Rationale 5: Peripheral edema is a manifestation of volume overload.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-3: Differentiate between the manifestations of left- and right-sided heart failure.

Question 21

Type: MCMA

While transferring a patient with heart failure from the bed to a chair the nurse stops and decides to keep the patient in bed. What patient manifestations indicated to the nurse this patients status was deteriorating?

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

Standard Text: Select all that apply.

1. Respiratory rate 30

2. Heart rate 134 on the cardiac monitor

3. Gasping for breath

4. Productive cough

5. Jugular vein distention

Correct Answer: 1,2,3

Rationale 1: Tachypnea is an indication of worsening heart failure.

Rationale 2: Tachycardia is an indication of worsening heart failure.

Rationale 3: Dyspnea is an indication of worsening heart failure.

Rationale 4: A productive cough is not an indication that the heart failure is becoming worse.

Rationale 5: Jugular vein distention is not an indication that the heart failure is becoming worse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-3: Differentiate between the manifestations of left- and right-sided heart failure.

Question 22

Type: MCSA

The central venous pressure of a patient with heart failure is slowly increasing. What does this finding suggest to the nurse?

1. Right heart function is deteriorating.

2. Left heart function is deteriorating.

3. Fluid is backing up in the lungs.

4. Right heart function is improving.

Correct Answer: 1

Rationale 1: Elevations in right filling pressures, such as the central venous pressure, can cause systemic venous pressure elevations leading to peripheral edema and ascites. These are symptoms of right heart failure.

Rationale 2: Elevated central venous pressure is not an indication of left heart function.

Rationale 3: An elevated central venous pressure does not assess left heart function.

Rationale 4: An elevated central venous pressure would indicate that right heart function is deteriorating and not improving.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-4: Describe the hemodynamic findings indicative of heart failure.

Question 23

Type: MCSA

A patient with heart failure begins to cough pink frothy sputum. Which pressure would the nurse assess to confirm this manifestation?

1. Central venous pressure

2. Pulmonary capillary wedge pressure

3. Arterial pressure

4. Right arterial pressure

Correct Answer: 2

Rationale 1: Central venous pressure would not be used to confirm the patients symptom.

Rationale 2: The pulmonary capillary wedge pressure would be elevated in pulmonary edema. This is the pressure that the nurse would assess to confirm the patients symptom.

Rationale 3: The arterial pressure would not be used to confirm the patients symptom.

Rationale 4: The right arterial pressure would not be used to confirm the patients symptom.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-4: Describe the hemodynamic findings indicative of heart failure.

Question 24

Type: MCMA

The nurse is teaching a patient with heart failure nonpharmacological strategies to improve quality of life. What will be included in these instructions?

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

Standard Text: Select all that apply.

1. Importance of smoking cessation

2. Reduce salt intake to 1 gram per day

3. Restrict caloric intake to attain recommended body weight

4. Attend cardiac rehabilitation sessions as prescribed

5. Ingest no more than three alcoholic drinks per day

Correct Answer: 1,3,4

Rationale 1: One nonpharmacological strategy to improve the quality of life in a patient with heart failure is to stop smoking.

Rationale 2: Salt intake should be restricted to 2 to 3 grams per day.

Rationale 3: Weight reduction in obese patients is a nonpharmacological strategy to improve the quality of life in the patient with heart failure.

Rationale 4: One nonpharmacological strategy to improve the quality of life in the patient with heart failure is to attend cardiac rehabilitation.

Rationale 5: To improve the quality of life in patients with heart failure, alcohol intake should be restricted.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 7-5: Explain collaborative management of the patient with heart failure.

Question 25

Type: MCMA

A patient a history of type 2 diabetes mellitus and heart failure is prescribed carvedilol (Coreg). What will the nurse assess prior to administering this medication to 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. Blood pressure

2. Pulse

3. Blood glucose level

4. Lung sounds

5. Potassium level

Correct Answer: 1,2,3

Rationale 1: Prior to administering a beta blocker, the nurse should assess the patients blood pressure to ensure it is adequate.

Rationale 2: Prior to administering a beta blocker, the nurse should assess the patients pulse to ensure it is adequate.

Rationale 3: The blood glucose level should be monitored in the patient with diabetes because a beta blocker can worsen glucose control and blunt symptoms of hypoglycemia.

Rationale 4: Lung sounds should be assessed in the patient with asthma and COPD prior to administering a beta block because of bronchoconstriction effects. The patient does not have asthma or COPD.

Rationale 5: The potassium level does not need to be assessed prior to administering a beta blocker to the patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-5: Explain collaborative management of the patient with heart failure.

Question 26

Type: MCMA

What findings identified by the nurse on an assessment of a patient being treated for heart failure would cause the nurse to notify the patients health care provider that the patients status was deteriorating?

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

Standard Text: Select all that apply.

1. S3 and S4 heart sounds

2. Oxygen saturation 80% on 4 liters oxygen nasal cannula

3. Urine output 10 mL over the last hour

4. Onset of production cough

5. Weight loss of 3 lbs from previous weight

Correct Answer: 1,2,3,4

Rationale 1: S3 and S4 heart sounds indicate the patients cardiac status is deteriorating.

Rationale 2: Reduced oxygen saturation is an indication that the patients pulmonary status is deteriorating.

Rationale 3: Poor urine output is an indication that the patients systemic status is deteriorating.

Rationale 4: Worsening cough is an indication that the patients pulmonary status is deteriorating.

Rationale 5: Weight loss is not an indication that the patients health status is deteriorating.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-6: Describe the patient with acute decompensated heart failure.

Question 27

Type: MCSA

A patient with heart failure is experiencing increased fatigue and has a weight gain of 1 kg. The nurse realizes this patient is demonstrating signs of:

1. Systemic deterioration

2. Pulmonary deterioration

3. Cardiac deterioration

4. Renal deterioration

Correct Answer: 1

Rationale 1: Signs of systemic deterioration include weight gain and fatigue.

Rationale 2: Weight gain and fatigue are not signs of pulmonary deterioration.

Rationale 3: Weight gain and fatigue are not signs of cardiac deterioration.

Rationale 4: The renal status is not specifically assessed in the patient with heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-6: Describe the patient with acute decompensated heart failure.

Question 28

Type: MCMA

The nurse is preparing medications for the patient experiencing acute decompensated heart failure. Which medications will be administered first to improve gas exchange 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. Morphine sulfate

2. Nitroglycerin

3. Nesiritide (Natrecor)

4. Dobutamine (Dobutrex)

5. Milrinone (Primacor)

Correct Answer: 1,2

Rationale 1: This medication is used to reduce patient anxiety during acute decompensated heart failure.

Rationale 2: This medication is used to reduce preload and pulmonary wedge pressure.

Rationale 3: This medication is used for the patient with acute decompensated heart failure who has dyspnea at rest and is not a medication that would be provided first.

Rationale 4: This medication is used to treat cardiogenic shock.

Rationale 5: This medication is used to treat cardiogenic shock.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-7: Describe collaborative management strategies appropriate for the patient with acute decompensated heart failure.

Question 29

Type: MCMA

A patient has been receiving milrinone (Primacor) for cardiogenic shock from acute decompensated heart failure. What findings indicate that this medication has been effective in 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. Increased cardiac output

2. Reduced pulmonary arterial wedge pressure

3. Dropping blood pressure

4. Onset of ventricular dysrhythmias

5. Respiratory rate 28 and regular

Correct Answer: 1,2

Rationale 1: An expected action of this medication is an increase in cardiac output.

Rationale 2: An expected action of this medication is a decrease in pulmonary arterial wedge pressure.

Rationale 3: Hypotension is a side effect of this medication and does not necessarily indicate that the medication has been effective in the patient.

Rationale 4: Ventricular dysrhythmias are side effects of this medication and do not necessarily indicate that the medication has been effective in the patient.

Rationale 5: This medication does not affect respiratory rate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7-7: Describe collaborative management strategies appropriate for the patient with acute decompensated heart failure.

Question 30

Type: MCSA

A patient with heart failure is scheduled for an echocardiogram and cardiac catheterization. The nurse would document that these diagnostic tests fulfill which heart failure core measure?

1. Evaluation of LVS

2. Discharge education

3. ACE-I or ARB for LVSD

4. Adult smoking cessation advice/counseling

Correct Answer: 1

Rationale 1: To fulfill this measure, the patient will have had left ventricular systolic function evaluated through the use of an echocardiogram or cardiac catheterization before hospitalization, during hospitalization, or is planned for after discharge.

Rationale 2: Tests to assess left ventricular systolic function are not included in the discharge education measure.

Rationale 3: Tests to assess left ventricular systolic function are not included in the ACE-I or ARB for LVSD measure.

Rationale 4: Tests to assess left ventricular systolic function are not included in the adult smoking cessation advice/counseling measure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Communication and Documentation

Learning Outcome: 7-8: Define the core measures for heart failure management.

Question 31

Type: MCSA

The nurse is preparing adult smoking cessation material for a patient admitted with heart failure. What criteria did the nurse use to determine that the patient should receive this material?

1. Patient smoked cigarettes any time during the last year prior to hospitalization

2. Patient uses chewing tobacco

3. Patient smokes five cigars a week

4. Patient stopped smoking five years prior to hospitalization

Correct Answer: 1

Rationale 1: For the Adult Smoking Cessation Advice/Counseling heart failure core measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.

Rationale 2: The use of chewing tobacco is not included in the criteria for the Adult Smoking Cessation Advice/Counseling for heart failure core measure.

Rationale 3: Smoking cigars is not included in the criteria for the Adult Smoking Cessation Advice/Counseling for heart failure core measure.

Rationale 4: This is not the definition of a smoker for the Adult Smoking Cessation Advice/Counseling for heart failure core measure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7-8: Define the core measures for heart failure management.

Question 32

Type: MCMA

The nurse is preparing discharge instructions for a patient admitted with heart failure. What will the nurse include in this teaching?

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

Standard Text: Select all that apply.

1. Permitted activity level

2. Diet

3. Prescribed medications

4. Importance of daily weight monitoring

5. Stress reduction strategies

Correct Answer: 1,2,3,4

Rationale 1: Permitted activity level should be included in discharge education for the patient with heart failure.

Rationale 2: Diet should be included in discharge education for the patient with heart failure.

Rationale 3: Medications should be included in discharge education for the patient with heart failure.

Rationale 4: Weight monitoring should be included in discharge education for the patient with heart failure.

Rationale 5: Stress reduction strategies are not identified as part of discharge education for the patient with heart failure.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 7-8: Define the core measures for heart failure management.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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