ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 29 : Management of Patients With Complications from Heart Disease Questions
Question 1 of 5
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?
Correct Answer: A
Rationale: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of HF.
Question 2 of 5
An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patients 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 patients subsequent care, what nursing diagnosis should be identified?
Correct Answer: D
Rationale: The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The patients medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all patients with HF, but this is not in evidence for this patient at this time.
Question 3 of 5
The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patients sensorium and LOC. Why is the assessment of the patients sensorium and LOC important in patients with HF?
Correct Answer: A
Rationale: As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in patients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular.
Question 4 of 5
Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following?
Correct Answer: A
Rationale: During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute. This rate is the resuscitators goal; the aim is not to give compressions as rapidly as possible. Compressions are not stopped after 10 compressions to allow for a breath or for full vital signs monitoring.
Question 5 of 5
The nurse is providing patient education prior to a patients 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?
Correct Answer: A
Rationale: Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.