ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 28 : Caring for Clients With Heart Failure Questions
Question 1 of 5
A client in the hospital informs the nurse he 'feels like his heart is racing and can't catch his breath.' What does the nurse understand occurs as a result of a tachyarrhythmia?
Correct Answer: B
Rationale: Reducing ventricular ejection volume because diastole, during which the ventricle fills with blood (preload), is shortened as a result of a tachyarrhythmia. Causing a loss of elasticity in the muscle is a result of cardiomyopathy. Afterload is decreased not increased.
Question 2 of 5
A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?
Correct Answer: C
Rationale: The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minute is within normal range as well as the respiratory rate and oxygen saturation.
Question 3 of 5
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, 'I cannot catch my breath.' How would the nurse document this finding?
Correct Answer: D
Rationale: Exertional dyspnea is the effort at breathing when active. Answer A is vague and does not give a more detailed explanation for documentation purposes. Orthopnea is the inability to breathe unless sitting upright, and paroxysmal nocturnal dyspnea is being awakened by breathlessness.
Question 4 of 5
The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information?
Correct Answer: A
Rationale:
To determine if a client is having orthopnea, the nurse needs to ask about the inability to breathe unless sitting upright. Determining how far the client can walk without becoming short of breath would indicate exertional dyspnea. Coughing up blood would indicate hemoptysis. Urinating excessively at night can be indicative of different factors such as taking a diuretic late in the evening causing the client to urinate often at night. This question would be vague.
Question 5 of 5
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
Correct Answer: B
Rationale: Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia.