Professional Documents
Culture Documents
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.
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.
9. Which client is at highest risk for the development of highoutput heart failure?
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.
3
: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.
4
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.
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.
5
d. Continuing, loud diastolic murmur radiating to the left
axilla
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.
:B
The mitral valve separates the left atrium from the left
ventricle. The prolapse permits backflow of blood during midto late systole, resulting in a midsystolic click and a late
systolic murmur at the heart apex.
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.
7
: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.
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.
: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.
:B
These agents cause immunosuppression, leaving the client
more vulnerable to infection.
8
: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.
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."
: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.
:A
A proportional pulse pressure less than 25% is indicative of a
severely compromised cardiac output. The proportional pulse
: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.
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.
:B
Follow-up by the multidisciplinary team decreases the
incidence of frequent hospitalizations by maintaining tighter
evaluation and control.
MULTIPLE RESPONSE