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
Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?
Correct Answer: B
Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.
Question 2 of 5
The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patients diagnosis?
Correct Answer: B
Rationale: Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers do not apply.
Question 3 of 5
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?
Correct Answer: A
Rationale: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.
Question 4 of 5
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?
Correct Answer: A
Rationale: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.
Question 5 of 5
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?
Correct Answer: B
Rationale: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.