6583742
Descrição
Quiz por Jessica Levine, atualizado more than 1 year ago
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Criado por Jessica Levine
aproximadamente 8 anos atrás
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Questão 1
Questão
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?
Responda
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Pericarditis
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Cardiomyopathy
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Pulmonary edema
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Right ventricular hypertrophy
Questão 2
Questão
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)?
Responda
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The patient takes Lasix (furosemide) 20 mg/day.
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The patient’s potassium level is 4.7 mEq/L.
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The patient is an African American man.
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The patient’s age is greater than 65.
Questão 3
Questão
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?
Responda
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Endocarditis
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Pleural effusion
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Atherosclerosis
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Atrial-septal defect
Questão 4
Questão
Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?
Responda
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Monitor liver function studies
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Monitor for hypotension
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Assess the patient’s vitamin D intake
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Assess the patient for hyperkalemia
Questão 5
Questão
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?
Responda
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Pulmonary edema
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Distended neck veins
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Dry cough
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Orthopnea
Questão 6
Questão
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?
Responda
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Confusion and bradycardia
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Uncontrolled diuresis and tachycardia
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Numbness and tingling in the extremities
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Chest pain and shortness of breath
Questão 7
Questão
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?
Responda
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Stroke
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Myocardial infarction (MI)
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Hemorrhage
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Peripheral edema
Questão 8
Questão
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?
Responda
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Skin turgor
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Potassium level
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White blood cell count
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Peripheral pulses
Questão 9
Questão
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?
Responda
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Check for a carotid pulse.
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Apply supplemental oxygen.
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Give two full breaths.
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Gently shake and shout, “Are you OK?”
Questão 10
Questão
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?
Responda
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Right-sided heart failure
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Acute pulmonary edema
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Pneumonia
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Cardiogenic shock
Questão 11
Questão
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?
Responda
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In a high Fowler’s position
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On the left side-lying position
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In a flat, supine position
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In the Trendelenburg position
Questão 12
Questão
The nurse has entered a patient’s room and found the patient unresponsive and not breathing. What is the nurse’s next appropriate action?
Responda
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Palpate the patient’s carotid pulse.
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Illuminate the patient’s call light.
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Begin performing chest compressions.
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Activate the Emergency Response System (ERS).
Questão 13
Questão
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?
Responda
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Monitor her blood pressure daily
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Assess her radial pulses daily
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Monitor her weight daily
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Monitor her bowel movements
Questão 14
Questão
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?
Responda
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Jugular vein distention
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Right upper quadrant pain
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Bibasilar fine crackles
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Dependent edema
Questão 15
Questão
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?
Responda
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“I will have a ham and cheese sandwich for lunch.”
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“I will have a baked potato with broiled chicken for dinner.”
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“I will have a tossed salad with cheese and croutons for lunch.”
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“I will have chicken noodle soup with crackers and an apple for lunch.”
Questão 16
Questão
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?
Responda
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Elevate the patient’s head to 90 degrees.
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Press the right upper abdomen.
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Press above the patient’s symphysis pubis.
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Lay the patient flat in bed.
Questão 17
Questão
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?
Responda
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The patient admitted with acute renal failure
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The patient admitted following an MI
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The patient admitted with malignant hypertension
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The patient admitted following a stroke
Questão 18
Questão
When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?
Responda
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A diastolic blood pressure that is lower during exhalation
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A diastolic blood pressure that is higher during inhalation
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A systolic blood pressure that is higher during exhalation
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A systolic blood pressure that is lower during inhalation
Questão 19
Questão
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?
Responda
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Pulseless electrical activity (PEA)
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Ventricular fibrillation
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Ventricular tachycardia
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Asystole
Questão 20
Questão
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?
Responda
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Teach the patient deep breathing and coughing exercises.
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Administer supplemental oxygen at all times.
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Limit the patient’s activity level.
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Avoid positioning the patient supine.
Questão 21
Questão
The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient’s care?
Responda
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Improve functional status
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Prevent endocarditis
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Extend survival
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Limit physical activity
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Relieve patient symptoms
Questão 22
Questão
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?
Responda
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Blood pressure
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Level of consciousness (LOC)
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Assessment for nausea
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Oxygen saturation
Questão 23
Questão
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?
Responda
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A beta-adrenergic blocker
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An antiplatelet aggregator
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A calcium channel blocker
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A nonsteroidal anti-inflammatory drug (NSAID)
Questão 24
Questão
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?
Responda
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Loop diuretic and antiplatelet aggregator
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Loop diuretic and calcium channel blocker
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Combination of hydralazine and isosorbide dinitrate
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Combination of digoxin and normal saline
Questão 25
Questão
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?
Responda
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Educating the patient that symptom relief may not occur for several weeks
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Stressing that symptom relief may take up to 4 months to occur
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Making adjustments to each day’s dose based on the blood pressure trends
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Educating the patient about the potential changes in LOC that may result from the drug
Questão 26
Questão
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?
Responda
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An S3 heart sound
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Pleural friction rub
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Faint breath sounds
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A heart murmur
Questão 27
Questão
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?
Responda
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Risk for ineffective tissue perfusion related to dysrhythmia
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Risk for fluid volume excess related to medication regimen
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Risk for ineffective breathing pattern related to hypoxia
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Risk for falls related to hypotension
Questão 28
Questão
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?
Responda
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HF ultimately affects oxygen transportation to the brain.
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Patients with HF are susceptible to overstimulation of the sympathetic nervous system.
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Decreased LOC causes an exacerbation of the signs and symptoms of HF.
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The most significant adverse effect of medications used for HF treatment is altered LOC.
Questão 29
Questão
Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following?
Responda
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Perform at least 100 chest compressions per minute.
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Pause to allow a colleague to provide a breath every 10 compressions.
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Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes.
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Perform high-quality chest compressions as rapidly as possible.
Questão 30
Questão
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?
Responda
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Know how to recognize and prevent orthostatic hypotension.
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Weigh yourself weekly at a consistent time of day.
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Measure everything you eat and drink until otherwise instructed.
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Limit physical activity to only those tasks that are absolutely necessary.
Questão 31
Questão
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?
Responda
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Avoid drinking fluids for 2 hours after taking the diuretic.
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Take the diuretic in the morning to avoid interfering with sleep.
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Avoid taking the medication within 2 hours consuming dairy products.
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Take the diuretic only on days when experiencing shortness of breath.
Questão 32
Questão
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?
Responda
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“Do not exercise unsupervised.”
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“Eventually aim to work up to 30 minutes of exercise each day.”
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“Slow down if you get dizzy or short of breath.”
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“Start your exercise program with high-impact activities.”
Questão 33
Questão
The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.
Responda
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Facilitate the presence of friends and family whenever possible.
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Teach the patient about the harmful effects of anxiety on cardiac function.
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Provide supplemental oxygen, as needed.
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Provide validation of the patient’s expressions of anxiety.
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Administer benzodiazepines two to three times daily.
Questão 34
Questão
The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply.
Responda
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Platelet level
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Fluid status
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Cardiac rhythm
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Action of medications
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Sputum volume
Questão 35
Questão
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?
Responda
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Rapidly assess the patient’s cardiopulmonary status.
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Arrange for an ECG.
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Increase the height of the patient’s bed.
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Manage the patient’s anxiety.
Questão 36
Questão
The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action?
Responda
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Lay the patient flat.
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Notify the family of the patient’s critical state.
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Stay with the patient.
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Update the physician.
Questão 37
Questão
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?
Responda
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Acute pulmonary edema
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Right-sided HF
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Right ventricular hypertrophy
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Left-sided HF
Questão 38
Questão
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?
Responda
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Atrial fibrillation
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Infective endocarditis
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Recurrent pneumonia
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Recent surgery
Questão 39
Questão
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?
Responda
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Pulmonary edema
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Pericardiocentesis
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Cardiac tamponade
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Pericarditis
Questão 40
Questão
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?
Responda
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Insertion of an implantable cardioverter defibrillator
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Insertion of an implantable pacemaker
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Administration of a calcium channel blocker
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Administration of a beta-blocker
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