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
The student nurse is caring for a client with heart failure. Diuretics have been prescribed. What method might be used with a debilitated client to help the nurse evaluate the client's response to diuretics?
Correct Answer: B
Rationale:
To evaluate response to diuretics, a urinary catheter is used. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. A biventricular pacemaker is used to sustain life.
Question 2 of 5
The nurse is working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for the nurse to closely monitor an older adult receiving digitalis preparations for cardiac disorders?
Correct Answer: A
Rationale: Older adults receiving digitalis preparations are at increased risk for toxicity because of the decreased ability of the kidneys to excrete the drug due to age-related changes. The margin between a therapeutic and toxic effect of digitalis preparations is narrow. Using digitalis preparations does not increase the risk of cardiac arrests, hyperthyroidism, or asthma.
Question 3 of 5
A client diagnosed with heart failure has been admitted to the ICU prior to invasive treatment. What treatment could be considered curative for this client?
Correct Answer: C
Rationale: A procedure known as surgical ventricular restoration (SVR) decreases the size of the heart to a near normal size and shape by removing dysfunctional heart muscle that does not contract properly. Once the adynamic (nonfunctioning) area is removed, the ventricle is repaired with a patch. In the cases that were studied, 91% were free of congestive heart failure after surgery with an ejection fraction that increased from 30% to 40%. A cardiomyoplasty, placement of an external pacemaker, or a ventricular assist device are not considered curative for heart failure.
Question 4 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 5 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.