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 with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
Correct Answer: B
Rationale: Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.
Question 2 of 5
The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?
Correct Answer: A
Rationale: Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area. The other options are not descriptive of pitting edema.
Question 3 of 5
A client with severe mitral valve insufficiency has been admitted to the unit. The client has heart failure and has developed pulmonary edema. What would be the best course of treatment for this client?
Correct Answer: C
Rationale: If the cause of heart failure and pulmonary edema can be corrected surgically (e.g., a mitral valve disorder), the client is supported medically while being prepared for surgery. The other options do not have the potential to reverse or stabilize this client's disease process, so they would not be the best treatment option.
Question 4 of 5
The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?
Correct Answer: A
Rationale: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm cor pulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart's conduction system.
Question 5 of 5
A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?
Correct Answer: A
Rationale: Class I is when ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.