NURS 24 EXAM 3 CHAPTER 29
The nurse is caring for a client with suspected right-sided heart failure. What would
✅✅
the nurse know that clients with suspected right-sided heart failure may experience?
- -Gradual unexplained weight gain
Clients with right-sided heart failure may have a history of gradual, unexplained
weight gain from fluid retention. Left-sided heart failure produces paroxysmal
nocturnal dyspnea, which may prompt the client to use several pillows in bed or to
sleep in a chair or recliner. Right-sided heart failure does not cause increased
perspiration or increased urine output.
A client has been having cardiac symptoms for several months and is seeing a
✅✅
cardiologist for diagnostics to determine the cause. How will the client's ejection
fraction be measured? - -Echocardiogram
Frequently, what is the earliest symptom of left-sided heart failure? - ✅✅-dyspnea
on exertion
A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse
100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in
✅✅
both lung bases; nausea; and pulse oximeter reading of 89%. Which finding
indicates a need for immediate attention? - -Lung congestion
A client with congestive heart failure is admitted to the hospital after reporting
✅✅
shortness of breath. How should the nurse position the client in order to decrease
preload? - -Head of the bed elevated 45 degrees and lower arms supported by
pillows
The nurse completes an assessment of a client admitted with a diagnosis of
✅✅
right-sided heart failure. What will be a significant clinical finding related to
right-sided heart failure? - -Pitting edema
The presence of pitting edema is a significant sign of right-sided heart failure
because it indicates fluid retention of about 10 lbs. Sodium and water are retained
because reduced cardiac output causes a compensatory neurohormonal response.
Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a
thickened left ventricle, seen with aortic stenosis or hypertension. The decreased
oxygen saturation levels are from hypoxemia.
The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic
✅✅
balloon pump (IABP). What is the therapeutic effect of the IABP therapy? -
-decreased left ventricular workload
, The nurse is teaching a client about medications prescribed for severe volume
✅✅
overload from heart failure. What diuretic is the first-line treatment for clients
diagnosed with heart failure? - -furosemide
A client asks the nurse if systolic heart failure will affect any other body function.
✅✅
What body system response correlates with systolic heart failure (HF)? -
-decrease in renal perfusion
A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction
causes the release of renin by the kidney. Systolic HF results in decreased blood
volume being ejected from the ventricle. Sympathetic stimulation causes
vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not
correlate with systolic heart failure.
✅✅
A nurse is administering digoxin. What client parameter would cause the nurse to
hold the digoxin and notify the health care prescriber? - -heart rate of 55 beats
per minute
While auscultating the heart sounds of a client with heart failure, the nurse hears an
✅✅
extra heart sound immediately after the second heart sound (S2). How should the
nurse document this sound? - -a third heart sound (S3).
✅✅
The nurse is obtaining data on an older adult client. What finding may indicate to the
nurse the early symptom of heart failure? - -Dyspnea on exertion
Which nursing intervention should the nurse perform when a client with valvular
✅✅
disorder of the heart has a heart rate less than 60 beats/min before administering
beta-blockers? - -Withhold the drug and inform the primary health care
provider.
✅✅
A client arrives at the ED with an exacerbation of left-sided heart failure and reports
shortness of breath. Which is the priority nursing intervention? - -Assess
oxygen saturation
✅✅
Which action will the nurse include in the plan of care for a client admitted with acute
decompensated heart failure (ADHF) who is receiving milrinone? - -Monitor
blood pressure frequently
A client has been experiencing increasing shortness of breath and fatigue. The
health care provider has ordered a diagnostic test in order to determine what type of
✅✅
heart failure the client is having. What diagnostic test does the nurse anticipate being
ordered? - -An echocardiogram
✅✅
The nurse is assessing a client with crackling breath sounds or pulmonary
congestion. What is the cause of the congestion? - -inadequate cardiac output
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