Chapter 29

The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem?

The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patient’s risk for heart failure (HF)?

The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patient’s medical history, what is a potential primary cause of the patient’s heart failure?

Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?

The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patient’s diagnosis?

The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms?

A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela?

The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum?

The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first?

A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?

A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient?

The nurse has entered a patient’s room and found the patient unresponsive and not breathing. What is the nurse’s next appropriate action?

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting?

The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure?

A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurse’s nutritional teaching plan has been effective?

The nurse’s comprehensive assessment of a patient who has HF includes evaluation of the patient’s hepatojugular reflux. What action should the nurse perform during this assessment?

The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock?

When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?

The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurse’s rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm?

The nurse is reviewing a newly admitted patient’s electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?

A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment?

The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient?

The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs?

A patient with a diagnosis of HF is started on a beta-blocker. What is the nurse’s priority role during gradual increases in the patient’s dose?

The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF?

An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patient’s most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patient’s subsequent care, what nursing diagnosis should be identified?

The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patient’s sensorium and LOC. Why is the assessment of the patient’s sensorium and LOC important in patients with HF?

Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following?

The nurse is providing patient education prior to a patient’s discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist?

The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics?

The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with HF. What should the nurse teach this patient about exercise?

A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurse’s best action?

The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action?

A cardiac patient’s resistance to left ventricular filling has caused blood to back up into the patient’s circulatory system. What health problem is likely to result?

A patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patient’s health history creates a heightened risk of intracardiac thrombi?

Diagnostic imaging reveals that the quantity of fluid in a client’s pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication?

The nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical intervention can be performed that may extend the survival of the patient?