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IGGY 37.
1.A client with heart failure develops an increase in preload.
Which mechanism contributes to this increase?
a. A reduction in sympathetic stimulation
b. Stimulation of coronary baroreceptors
c. Activation of the renin-angiotensin-aldosterone system
d. Arterial vasodilation and subsequent increase in oxygen
consumption
ANS: C
Activation of the renin-angiotensin-aldosterone system
increases preload by contributing to vasoconstriction and fluid
retention, which in turn reduce the force of contraction and
cardiac output.

1. A client with heart failure develops an increase in preload.
Which mechanism contributes to this increase?
a. A reduction in sympathetic stimulation
b. Stimulation of coronary baroreceptors
c. Activation of the renin-angiotensin-aldosterone system
d. Arterial vasodilation and subsequent increase in oxygen
consumption
ANS: C
Activation of the renin-angiotensin-aldosterone system
increases preload by contributing to vasoconstriction and fluid
retention, which in turn reduce the force of contraction and
cardiac output.

DIF: Cognitive Level: Comprehension REF: p. 765

3.2. A client is admitted with early-stage heart failure. Which
immediate compensatory response would the nurse expect to
see in this client?
a. Decreased stroke volume, causing decreased urinary output
b. Arterial vasodilation, resulting in pooling of blood in the
extremities
c. Stimulation of adrenergic receptors, causing an increase in
heart rate
d. Myocardial hypertrophy, resulting in an initial increase in
oxygen saturation
-
ANS: C
In heart failure, stimulation of the sympathetic nervous system
represents the most immediate response. Adrenergic receptor
stimulation causes an increase in heart rate and respiratory rate.

DIF: Cognitive Level: Comprehension REF: p. 765
3. A client is admitted with early-stage heart failure. Which
assessment finding does the nurse expect?
a. A drop in blood pressure and urine output
b. An increase in creatinine and lower extremity edema
c. An increase in heart rate and respiratory rate
d. An increase in oxygen saturation

ANS: C
In heart failure, stimulation of the sympathetic nervous system
represents the most immediate response. Adrenergic receptor
stimulation causes an increase in heart rate and respiratory rate.
The blood pressure will remain the same or elevate slightly.


4. A client with systolic dysfunction has an ejection fraction of
38%. The nurse expects to observe which physiologic change?
a. An increase in stroke volume
b. A decrease in tissue perfusion
c. An increase in oxygen saturation
d. A decrease in arterial vasoconstriction
-

ANS: B
In systolic dysfunction, the ventricle is unable to contract with
enough force to eject blood effectively during systole. As the
ejection fraction decreases (50% to 70% is normal), tissue
perfusion decreases and the client develops activity
intolerances.


5. Which client is most at risk of developing left-sided heart
failure?
a. Middle-aged woman with aortic stenosis
b. Middle-aged man with pulmonary hypertension
c. Older woman who smokes two packs of cigarettes daily
d. Older man who has had a right ventricular myocardial
infarction
: A
Although most individuals with heart failure will have failure
that progresses from left to right, it is possible to have left-
sided failure alone for a short period. It is also possible to have
heart failure that progresses from right to left. Causes of left
ventricular failure include mitral or aortic valve disease, CAD
(coronary artery disease), and hypertension.


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6. Which client statement alerts the nurse to possible heart
failure?
a. "I am drinking more water than usual."
b. "I have been awakened by the need to urinate at night."
c. "I have to stop halfway up the stairs to catch my breath."
d. "I have experienced blurred vision on several occasions."
: C
Clients with left-sided heart failure report weakness or fatigue
while performing normal activities of daily living as well as
difficulty breathing, or "catching their breath." This occurs as
fluid moves into the alveoli.


7. A client with a history of myocardial infarction calls the
clinic to report the onset of a cough that is troublesome only at
night. What direction will the nurse give to the client?
a. "Come to the clinic for evaluation."
b. "Increase fluid intake during waking hours."
c. "Use an over-the-counter cough suppressant before going to
sleep."
d. "Use two pillows to facilitate drainage of postnasal
secretions."
: A
The client with a history of myocardial infarction is at risk for
developing heart failure. The onset of nocturnal cough is an
early manifestation of heart failure, and the client needs to be
evaluated as soon as possible.


8. Which statement made by a client would alert the nurse to
the possibility of right-sided heart failure?
a. "I sleep with four pillows at night."
b. "My shoes fit really tight."
c. "I wake up coughing every night."
d. "I have trouble catching my breath."
: B
Signs of systemic congestion occur with right-sided heart
failure. Fluid is retained, pressure builds in the venous system,
and peripheral edema develops. Left-sided heart failure
symptoms include respiratory symptoms. Orthopnea, coughing,
and difficulty breathing could all be results of left-sided heart
failure.


9. Which client is at highest risk for the development of high-
output heart failure?
a. Young woman taking oral contraceptives
b. Middle-aged man who broke an ankle while training for a
marathon
c. Older adult with dehydration 5 years after having a
myocardial infarction
d. Young woman taking large doses of Synthroid to promote
weight loss
: D
Hyperthyroidism, whether caused by increased synthesis of
thyroid hormones or overdose of exogenous thyroid hormone,
increases heart rate and contractility. This can increase the
workload of the heart without allowing sufficient time for
perfusion and oxygenation.


10. The nurse notes that the client's apical pulse is displaced to
the left. What conclusion can be drawn from this assessment?
a. This is a normal finding.
b. The heart is hypertrophied.
c. The left ventricle is contracted.
d. The client has pulsus alternans.
: B
The client with heart failure typically has an enlarged heart
that displaces the apical pulse to the left.


11. The nurse assesses a client and notes the presence of an S3
gallop. Which is the nurse's priority intervention?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the health care provider immediately.
d. Transfer the client to the intensive care unit.
: A
The presence of an S3 gallop is an early diastolic filling sound
indicative of increasing left ventricular pressure and left
ventricular failure.

12. A client asks the nurse why it is important to be weighed
every day if he or she has right-sided heart failure. How will
the nurse respond?
a. "Weight is the best indication that you are gaining or losing
fluid."
b. "Weighing you every day will help us make sure that you're
eating properly."
c. "The hospital requires that all inpatients be weighed daily."
d. "You need to lose weight to decrease the incidence of heart
failure."
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: A
Daily weights are needed to document fluid retention or fluid
loss. One liter of fluid equals 2.2 pounds.


13. A client has been admitted to the intensive care unit with
worsening pulmonary manifestations of heart failure. Which
primary collaborative intervention should the nurse perform?
a. Maintain the head of the bed in a high Fowler's position.
b. Keep the client on bedrest, with passive range of motion.
c. Limit visitors and activity to a minimum.
d. Administer loop diuretics.
: D
The client with worsening heart failure is most at risk for
pulmonary edema as a consequence of fluid retention.
Administering the diuretics will decrease the fluid overload,
thereby decreasing the incidence of pulmonary edema.


14. Which nursing diagnosis would be considered a priority
for the client with heart failure?
a. Anxiety related to hospitalization
b. Altered Health Maintenance
c. Impaired Gas Exchange
d. Altered Comfort
: C
The client with heart failure experiences impaired gas
exchange related to inadequate cardiac pump function.
Although all other diagnoses presented here may be
manifested, Impaired Gas Exchange is the priority because it
is the most life-threatening.

15. The client with heart failure is experiencing respiratory
difficult. Which is the nurse's priority action?
a. Place the client in a high Fowler's position.
b. Suction the client.
c. Auscultate the client's heart and lungs.
d. Place the client on fluid restriction.
: A
Placing a client in a high Fowler's position, especially with
pillows under each arm, can maximize chest expansion and
improve oxygenation.


16. The client with heart failure is prescribed enalapril
(Vasotec). What is the nurse's focus for teaching?
a. Avoiding salt substitutes
b. Taking medication with food
c. Avoiding aspirin or aspirin-containing products
d. Holding this medication if the pulse rate is below 74
beats/min
: A
Angiotensin-converting enzyme (ACE) inhibitors inhibit the
excretion of potassium. Hyperkalemia can be a life-
threatening side effect, and clients should be taught to limit
potassium intake. Salt substitutes are composed of potassium
chloride.


17. Which is the priority intervention for a client who has
received the first dose of captopril (Capoten)?
a. Administer this medication 1 hour before meals to aid
absorption.
b. Instruct the client to ask for assistance when arising from
bed.
c. Give the medication with milk to prevent stomach upset.
d. Monitor the potassium level for hypokalemia.
: B
Administration of the first dose of ACE inhibitors is
associated with hypotension, usually termed first-dose effect.
The nurse should instruct the client to seek assistance before
arising from bed to prevent injury from postural hypotension.


18. The client with moderate heart failure is being discharged.
Which is of priority to teach the client?
a. "Avoid drinking more than 3 quarts of liquids each day."
b. "Stop your activity and rest at the first sign of chest pain."
c. "Weigh yourself every day in the morning before
breakfast."
d. "Do not take a double dose if you forget to take your
digoxin."
: C
Weight gain is the most reliable indicator of fluid retention
associated with heart failure. The client should weigh himself
or herself early in the morning, before breakfast. The client
should be instructed to limit fluid; 3 quarts is too much fluid
for the client.


19. The client who just started taking isosorbide dinitrate
(Isordil) complains of a headache. What is the nurse's first
action?
a. Titrate oxygen to relieve headache.
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b. Hold the next dose of Isordil.
c. Instruct the client to drink water.
d. Administer PRN acetaminophen.
: D
The vasodilating effects of this drug frequently cause clients to
have headaches during the initial period of therapy. Clients
should be told about this side effect and encouraged to take the
medication with food. Some clients obtain relief with mild
analgesics, such as acetaminophen.


20. The client with heart failure has been ordered to receive a
daily nitroglycerin transdermal patch. Which is the priority
nursing intervention?
a. Placing an occlusive dressing over the patch
b. Removing the patch overnight
c. Rotating the skin site of nitroglycerin administration
d. Administering a larger loading dose before the initiation of
therapy
: B
Providing a 12-hour nitrate-free period out of every 24 hours
helps prevent the development of tolerance to the vasodilating
effects of nitrates.


21. Which intervention is essential to teach the client starting
on digoxin therapy?
a. "Avoid taking aspirin or aspirin-containing products."
b. "Increase fluid intake to at least 3000 mL/day."
c. "Do not take this medication if your pulse rate is below 80
beats/min."
d. "Do not take this medication within 1 hour of taking an
antacid."
: D
Gastrointestinal absorption of digoxin is erratic. Many
medications, especially antacids, interfere with its absorption.


22. A client is taking triamterene-hydrochlorothiazide
(Dyazide) and furosemide (Lasix). Which assessment finding
alerts the nurse to a serious side effect?
a. Cough
b. Headache
c. Bradycardia
d. Hypokalemia
: D
Hypokalemia is a side effect of both thiazide and loop
diuretics. The client loses electrolytes with fluid. Coughing is
not a typical side effect of this medication. Headaches may
occur with any medication, and is not a serious side effect.
Bradycardia is not likely to occur with this medication.


23. A client with heart failure is going through rehabilitation
to increase his or her activity tolerance. The nurse will stop the
client's activity if which symptom is assessed?
a. Oxygen saturation of 95%
b. Respiratory rate of 20 breaths/min
c. Systolic blood pressure change from 136 to 96 mm Hg
d. Heart rate increase from 86 to 100 beats/min
: C
A blood pressure change (increase or decrease) of more than
20 mm Hg during or after activity indicates poor cardiac
tolerance of the activity. A significant decrease (>20%) in
blood pressure during or following activity is especially
ominous, because it indicates an inability of the left ventricle
to maintain sufficient cardiac output.


24. An older adult client with heart failure has developed atrial
fibrillation.
What diagnostic or laboratory test would the nurse expect to
be ordered?
a. Serum anion gap
b. Serum sodium level
c. T4 (thyroxine) and TSH (thyroid-stimulating hormone)
d. Serum creatinine
: C
In older adults with atrial fibrillation, T4 and TSH levels
should be checked because hypo- or hyperthyroidism can
cause or aggravate heart failure.


25. Which assessment finding alerts the nurse to the
possibility of pulmonary edema in an older adult?
a. Confusion
b. Dysphagia
c. Sacral edema
d. Irregular heart rate
: A
Impending pulmonary edema is characterized by a change in
mental status, disorientation, and confusion, along with
dyspnea and increasing fluid levels in the lungs.

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26. A client with a history of heart failure is being discharged.
Which instruction will assist the client in the prevention of
complications associated with heart failure?
a. "Drink at least 2 L of fluids daily."
b. "Eat six small meals daily instead of three larger meals."
c. "When you feel short of breath, take an additional diuretic."
d. "Weigh yourself daily wearing the same amount of
clothing."
: D
Clients with heart failure are instructed to weigh themselves
daily to detect worsening heart failure early, and thus avoid
complications. Other signs of worsening heart failure are
increasing dyspnea, exercise intolerance, cold symptoms, and
nocturia.


27. A client has been admitted to the acute care unit for an
exacerbation of heart failure. Which is the nurse's priority
intervention?
a. Assessing respiratory status
b. Monitoring the serum electrolyte levels
c. Administering intravenous fluids
d. Inserting a Foley catheter
: A
Assessment of respiratory and oxygenation status is the
priority nursing intervention for the prevention of
complications.


28. Which assessment finding supports a diagnosis of
impaired tissue perfusion in the client with heart failure?
a. Carotid bruit
b. A dry hacking cough
c. A positive Allen's test
d. Dyspnea on exertion
: D
Indications of poor tissue perfusion are activity intolerance,
which includes dyspnea on exertion.


29. Which assessment finding does the nurse expect in the
client with mitral valve prolapse?
a. Rumbling apical diastolic murmur
b. Midsystolic click and late systolic murmur
c. An S3 coupled with a high-pitched systolic murmur
d. Continuing, loud diastolic murmur radiating to the left
axilla
: B
The mitral valve separates the left atrium from the left
ventricle. The prolapse permits backflow of blood during mid-
to late systole, resulting in a midsystolic click and a late
systolic murmur at the heart apex.


30. What clinical manifestation alerts the nurse to the
possibility that the client's mitral stenosis has progressed?
a. The client's oxygen saturation is 92%.
b. The client has dyspnea on exertion.
c. The client has a systolic crescendo-decrescendo murmur.
d. The client experiences a loss of strength in the upper
extremities.
: B
The development of dyspnea on exertion occurs as the mitral
valvular orifice narrows and pressure in the lungs increases.


31. Which assessment finding does the nurse expect in a client
diagnosed with aortic stenosis?
a. Bounding arterial pulse
b. Slow, faint arterial pulse
c. Narrowed pulse pressure
d. Elevated systolic and diastolic pressures
: C
In aortic stenosis, the client presents with a narrowed pulse
pressure when the blood pressure is assessed.


32. Which assessment finding does the nurse expect in the
client with mitral insufficiency?
a. A systolic click on auscultation
b. A high-pitched holosystolic murmur
c. Angina with exertion
d. A cough with hemoptysis
: B
Incomplete closure of the mitral valve allows backflow of
blood into the left atrium when the ventricle contracts,
resulting in a holosystolic, high-pitched murmur

DIF: Cognitive Level: Knowledge REF: p. 779, Chart 37-7

6

33. The client who has had a prosthetic valve replacement asks
the nurse why he must take anticoagulants for the rest of his
life. How will the nurse respond?
a. "You are at greater risk for a heart attack, and the
anticoagulants can reduce that risk."
b. "Blood clots form more easily on artificial replacement
valves."
c. "The vein taken from your leg reduces circulation in the leg,
making blood return to the heart much slower."
d. "The surgery left a lot of small clots in your heart and lungs.
The anticoagulants will slowly dissolve these."
: B
Synthetic valve prostheses and scar tissue provide a surface on
which platelets can aggregate easily and initiate the formation
of blood clots.


34. A client has just undergone a balloon valvuloplasty. For
which complication of this procedure should the nurse monitor
this client?
a. Bleeding
b. Acute tubular necrosis
c. Short-term memory loss
d. Pulmonary hypertension
: A
Clients undergoing valvuloplasty are at higher risk of bleeding
from the catheter insertion site. This is because of the use of a
large-bore catheter for the arterial puncture needed to perform
the procedure.


35. A client is preparing to be discharged home following
mitral valve replacement. Which statement indicates that the
client requires further education?
a. "I won't be able to carry heavy loads for at least 6 months."
b. "I will have my teeth cleaned by the dentist in 2 weeks."
c. "I will avoid eating foods high in vitamin K."
d. "I can use my electric razor to shave."
: B
Clients who have defective or repaired valves are at high risk
of endocarditis. The client who has had valve surgery should
avoid dental procedures for 6 months because of the risk of
endocarditis. When undergoing any invasive procedure, the
client needs to be placed on prophylactic antibiotics.


36. A young adult presents with a fever, symptoms of heart
failure, and a murmur. Which additional data will the nurse
obtain?
a. Family history of coronary artery disease
b. Recent travel to third-world countries
c. Whether the client is responsible for cleaning pet litter
boxes
d. History of any systemic infection or dental work within the
past month
: D
The clinical manifestations suggest infective endocarditis,
which can occur within 2 to 4 weeks after a systemic infection
or bacteremia.


37. Which precautions are appropriate when providing care to
a client with infective endocarditis?
a. Standard precautions
b. Enteric precautions
c. Protective isolation
d. Respiratory isolation
: A
The client with infective endocarditis does not pose any
specific threat of transmitting the causative organism.


38. The home care nurse is assessing the client receiving
antibiotic therapy in the home for infective endocarditis.
Which of the following clinical manifestations requires re-
evaluation of the treatment regimen?
a. Temperature: 101.6 F
b. Clubbing of fingers
c. Petechiae
d. Pulse pressure of 36 mm Hg
: A
Persistent or new fever in a client receiving antibiotic therapy
for infective endocarditis may indicate inappropriate or
ineffective therapy.


39. The nurse has difficulty hearing heart sounds in a client
with pericarditis. Which is the priority action of the nurse?
a. Assessing heart sounds with a Doppler
b. Increasing the intravenous flow rate
c. Administering oxygen by non-rebreather mask
d. Assessing the client for Beck's triad
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: D
Heart sounds that become muffled or more difficult to
auscultate in a client with pericarditis may indicate the
presence of tamponade, a medical emergency. The health care
provider should be notified after assessment data is obtained.


40. Which assessment finding does the nurse expect in a client
with pericarditis?
a. An irregular heart rate that speeds up and slows down
b. A friction rub at the left lower sternal border
c. The presence of a gallop rhythm
d. A substernal lift at the apex
: B
The client with pericarditis may present with a pericardial
friction rub at the left lower sternal border. This sound is the
result of friction from inflamed pericardial layers when they
rub together.


41. A nurse is caring for a client admitted with tachycardia, a
pericardial friction rub, and the development of a murmur.
Which finding in the client's history leads the nurse to suspect
rheumatic carditis?
a. The client was vacationing in the tropics 2 weeks ago.
b. The client has had a sore throat for 1 week.
c. The client is currently taking antibiotics.
d. The client has a history of alcoholism.
: B
Rheumatic carditis is a sensitivity response occurring after
infection with group A beta-hemolytic streptococci. The
client's history of a sore throat is suspicious for rheumatic
carditis because of the clinical manifestations at admission.


42. Which instructions are essential in a teaching plan for a
client with hypertrophic cardiomyopathy (HCM)?
a. "Take your digoxin at the same time every day."
b. "You should begin an aerobic exercise program."
c. "You should report episodes of dizziness or fainting."
d. "You may have a maximum of two alcoholic drinks
weekly."
: C
The client with HCM is instructed to notify the health care
provider if episodes of fainting, dizziness, or palpitations
occur, because these may signal the onset of deadly
dysrhythmias. Clients with HCM are instructed to avoid
strenuous exercise and alcohol. Cardiac glycosides are
contraindicated in obstructive HCM.


43. The nurse cautions the client who has received a heart
transplant to change positions slowly. Why is this instruction a
priority?
a. Rapid position changes can create shear forces and disrupt
vascular sutures.
b. The new vascular connections are more sensitive to position
changes, leading to increased intravascular pressure.
c. The new heart is denervated and unable to respond to
decreases in blood pressure caused by position changes.
d. The recovering heart diverts blood flow away from the
brain when the client stands, increasing the risk for stroke.
: C
Because the new heart is denervated, the baroreceptor and
other mechanisms that compensate for blood pressure drops
caused by position changes do not function. This allows
orthostatic hypotension to persist in the postoperative period.

DIF: Cognitive Level: Application REF: N/A for Application
and above
OBJ: Learning Outcome 22
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation)
MSC: Integrated Process: Nursing Process (Implementation)

44. Which teaching is essential for a client discharged after a
heart transplant who is prescribed cyclosporine (Sandimmune)?
a. "Use a soft-bristled toothbrush."
b. "Avoid crowds and people who are sick."
c. "Change positions slowly to avoid hypotension caused by
the medication."
d. "Do not take this medication if your pulse rate is lower than
60 beats/min."
: B
These agents cause immunosuppression, leaving the client
more vulnerable to infection.


45. A client is classified (staged) at level A heart failure. What
will the nurse teach the client?
a. "Take digoxin daily."
b. "Limit activity when short of breath."
c. "Control blood pressure at 140/80 or below."
d. "Maintain a no added salt diet."
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: D
A stage A client is identified as a high risk for heart failure.
Education should be focused on the prevention of
hypertension, coronary artery disease, and valvular disease,
which are the leading causes of heart failure.


46. A client with end-stage heart failure is awaiting a
transplant. The client appears depressed and states, "I know a
transplant is my last chance but I don't want to become a
vegetable." What is the nurse's best response?
a. "Would you like to speak with a priest?"
b. "I'll get a psychiatrist to talk with you."
c. "Do you want to come off the transplant list?"
d. "Would you like information about advanced directives?"
: D
The client is verbalizing a real concern or fear about negative
outcomes of the surgery. This anxiety itself can have a
negative effect on the outcome of the surgery because of the
sympathetic stimulation. The best action is to allow her or him
to verbalize the concern and work toward a positive outcome
without making the client feel as though he or she is crazy.
The client needs to feel that he or she has some control over
the future.

47. Which question will best help the nurse to assess the
activity level of a client with a history of heart failure?
a. "Do you have trouble breathing or chest pain?"
b. "Are you able to walk up stairs without fatigue?"
c. "Do you wake up suddenly during the night with
breathlessness?"
d. "Do you become fatigued or develop heaviness in your
arms or legs that you didn't
have before?"
: D
Clients with a history of heart failure generally have negative
findings, such as shortness of breath. The nurse needs to
determine if the client's activity is the same or worse, or
whether the client identifies that there is a decrease in activity
level.


48. A client with heart failure has a blood pressure of 140/60
mm Hg. How will the nurse interpret this finding?
a. Normal proportional pulse pressure
b. Severely compromised cardiac output
c. Hypertensive blood pressure
d. Narrowed pulse pressure
: A
A proportional pulse pressure less than 25% is indicative of a
severely compromised cardiac output. The proportional pulse

49. An older adult client with heart failure states, "I don't
know what to do. I don't want to be a burden to my daughter,
but I can't do it alone. Maybe I should die." Which is the
nurse's best response?
a. "Would you like to talk about it more?"
b. "You're lucky to have such a devoted daughter."
c. "You feel as though you are a burden."
d. "You seem depressed. I'll get the doctor to order an
antidepressant."
: C
Depression can occur in clients with heart failure, especially
older adults. Having the client talk about his or her feelings
will help the nurse focus on the actual problem. Open-ended
statements allows the client to respond safely and honestly.


50. An older adult client is admitted with fluid volume excess.
Which diagnostic or laboratory study would best assist in the
diagnosis of heart failure?
a. Echocardiography
b. Chest x-ray
c. T4, TSH
d. Arterial blood gases
: A
Echocardiography is considered the best tool for the diagnosis
of heart failure.

DIF: Cognitive Level: Comprehension REF: p. 780


51. How will the nurse position the client in severe heart
failure?
a. High Fowler's, pillows under arms
b. Semi-Fowler's, with legs elevated
c. High Fowler's, with legs elevated
d. Semi-Fowler's, on their left side
: A Placing the client in a high Fowler's position, with pillows
under their arms, allows for maximum chest expansion.

9


52. A nurse is instructing a client with heart failure on energy
conservation. Which is the best instruction?
a. "Walk until you become short of breath and then walk back
home."
b. "Gather everything you need for a chore before you begin."
c. "Pull rather than push or carry items heavier than 5 pounds."
d. "Take a walk after dinner every day."
: B
Gathering all supplies needed for a chore at one time
decreases the amount energy needed.


53. A client with heart failure is due to receive enalapril
(Vasotec). The blood pressure is 98/50 mm Hg. Which is the
nurse's best action?
a. Administer the Vasotec.
b. Wait 1 hour and then administer the Vasotec.
c. Hold the Vasotec.
d. Notify the physician.
: A
The nurse should administer the medication. Generally, the
health care provider will maintain the client's blood pressure
between 90 and 110 mm Hg.

54. A client in severe heart failure is to receive nesiritide
(Natrecor). Which intervention is essential prior to starting this
medication?
a. Insert a separate IV access.
b. Prepare a test bolus dose.
c. Prepare the piggyback line.
d. Administer IV Lasix first.
: A
Natrecor should be given through a separate IV access because
it is incompatible with many medications, especially heparin.


55. In Healthy People 2010, which is a priority of the primary
nurse caring for older adults with heart failure?
a. Reduce hospitalizations by treating more clients at home.
b. Provide follow-up care by the multidisciplinary team.
c. Perform follow-up phone calls, delegated to the unit
secretary.
d. Evaluate client compliance with medications by the home
health aide.
: B
Follow-up by the multidisciplinary team decreases the
incidence of frequent hospitalizations by maintaining tighter
evaluation and control.

MULTIPLE RESPONSE

1. Which conditions are caused by left-sided heart failure?
(Select all that apply.)
a. Hypertensive disease
b. Crackles heard
c. Enlarged liver and spleen
d. Confusion
e. Pulmonary hypertension
f. Dependent edema
g. S3/S4 gallop
h. Cough worsens at night
: A, B, D, G, H
Left-sided failure occurs with decrease in contractility of the
heart or an increase in afterload. Most of the signs will be
noted in the respiratory system. Right-sided failure occurs
with problems from the pulmonary vasculature on. Signs will
be noted before the right atrium or ventricle.

DIF: Cognitive Level: Knowledge REF: p. 768, Charts 37-1
and 37-2

2. Which laboratory results does the nurse expect in the client
with heart failure? (Select all that apply.)
a. Hemoglobin, 14.2 g/dL; hematocrit (Hct), 32.8%
b. Serum sodium, 130 mEq/L
c. Serum potassium, 4.0 mEq/L
d. Serum creatinine, 1.0 mg/dL
e. Proteinuria
f. Microalbuminuria
: A, B, E, F
The hematocrit is low (should be 42.6%), indicating a
dilutional ratio of RBCs to fluid. The serum sodium is low
because of hemodilution. Microalbuminuria and proteinuria
are present, indicating a decrease in renal filtration. This is an
early warning sign of decreased compliance of the heart.