Exam (elaborations)
GNRS 555 - Cardiovascular (1)
GNRS 555 - Cardiovascular (1)
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Which of the following is correct about ventricular tachycardia?a. It always comes with no pulse.
b. It is a regular rhythm.
✅✅
c. It has narrow QRS.
d. It is clinically significant. - -d. It is clinically significant.
Which of the following is not true about ventricular fibrillation?
a. It is always irregular.
b. It is always pulseless.
✅✅-d. Atropine is the
c. It is a lethal dysrhythmia.
d. Atropine is the drug of choice of ventricular fibrillation. -
drug of choice of ventricular fibrillation.
T/F: The most serious dysrhythmias of all are the ventricular ones. - ✅✅-true
During assessment of a 72-year-old with ankle swelling, the nurse notes jugular
venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The
nurse knows this finding indicates:
a. decreased fluid volume.
b. jugular vein atherosclerosis.
✅✅-c. elevated right atrial pressure.
c. elevated right atrial pressure.
d. incompetent jugular vein valves. -
reason: The jugular veins empty into the superior vena cava and then into theright
atrium, so JVD with the patient sitting at a 45-degree anglereflects elevated right
atrial pressure. JVD is an indicator ofexcessive fluid volume (increased preload), not
decreased fluid volume.JVD is not caused by incompetent jugular vein valves or
atherosclerosis.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine
for the treatment of acute decompensated heart failure (ADHF) with severe
orthopnea. When evaluating the patient response to the medications, the best
indicator that the treatment has been effective is:
a. weight loss of 2 pounds overnight.
b. hourly urine output greater than 60 mL.
✅✅-d. decreased
c. reduction in patient complaints of chest pain.
d. decreased dyspnea with the head of bed at 30 degrees. -
dyspnea with the head of bed at 30 degrees.
,reason: Because the patient's major clinical manifestation of ADHF is orthopnea
(caused by the presence of fluid in the alveoli), the best indicator that the
medications are effective is a decrease in dyspnea with the head of the bed at 30
degrees. The other assessment data also may indicate that diuresis or improvement
in cardiac output has occurred but are not as specific to evaluating this patient's
response.
Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute
pulmonary edema. During the first hours of administration, the nurse will need to
adjust the nitroprusside rate if the patient develops:
a. a dry, hacking cough.
b. any ventricular ectopy.
✅✅-c. a systolic BP <90 mm Hg.
c. a systolic BP <90 mm Hg.
d. a heart rate <50 beats/minute. -
reason: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is
severe hypotension. Coughing and bradycardia are not adverse effects of this
medication. Nitroprusside does not cause increased ventricular ectopy.
A patient who has chronic heart failure tells the nurse, "I felt fine when I went to bed,
but I woke up in the middle of the night feeling like I was suffocating!" The nurse will
document this assessment information as:
a. pulsus alternans.
b. two-pillow orthopnea.
✅✅-d. paroxysmal nocturnal dyspnea.
c. acute bilateral pleural effusion.
d. paroxysmal nocturnal dyspnea. -
reason: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from
dependent body areas when the patient is sleeping and is characterized by waking
up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of
strong and weak peripheral pulses during palpation. Orthopnea indicates that the
patient is unable to lie flat because of dyspnea. Pleural effusions develop over a
longer time period.
During a visit to a 72-year-old with chronic heart failure, the home care nurse finds
that the patient has ankle edema, a 2-kg weight gain, and complains of "feeling too
tired to do anything." Based on these data, the best nursing diagnosis for the patient
is:
a. activity intolerance related to fatigue.
b. disturbed body image related to leg swelling.
c. impaired skin integrity related to peripheral edema.
, d. impaired gas exchange related to chronic heart failure. - ✅✅-a. activity
intolerance related to fatigue.
The nurse working in the heart failure clinic will know that teaching for a 74-year-old
patient with newly diagnosed heart failure has been effective when the patient:
a. uses an additional pillow to sleep when feeling short of breath at night.
b. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime.
c. calls the clinic when the weight increases from 124 to 130 pounds in a week.
✅✅
d. says that the nitroglycerin patch will be used for any chest pain that develops. -
-c. calls the clinic when the weight increases from 124 to 130 pounds in a
week.
reason: Teaching for a patient with heart failure includes information about the need
to weigh daily and notify the health care provider about an increase of 3 pounds in 2
days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce
preload (not to prevent chest pain) in patients with heart failure and should be used
daily, not on an "as necessary" basis. Diuretics should be taken earlier in the day to
avoid nocturia and sleep disturbance. The patient should call the clinic if increased
orthopnea develops, rather than just compensating by elevating the head of the bed
further.
When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse
explains that foods to be restricted include:
a. canned and frozen fruits.
b. fresh or frozen vegetables.
✅✅-c. milk, yogurt, and other milk
c. milk, yogurt, and other milk products.
d. eggs and other high-cholesterol foods. -
products.
reason: Milk and yogurt naturally contain a significant amount of sodium, and intake
of these should be limited for patients on a diet that limits sodium to 2000 mg daily.
Other milk products, such as processed cheeses, have very high levels of sodium
and are not appropriate for a 2000 mg sodium diet. The other foods listed have
minimal levels of sodium and can be eaten without restriction.
The nurse plans discharge teaching for a patient with chronic heart failure who has
prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL).
Appropriate instructions for the patient include:
a. avoid dietary sources of potassium.
b. take the hydrochlorothiazide before bedtime.
c. notify the health care provider about any nausea.
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