ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 28 Questions
Question 1 of 5
What disease process(es) contributes to chronic heart failure? Select all that apply.
Correct Answer: A,B,D
Rationale: Hypertension, tachyarrhythmias, valvular disease, cardiomyopathy, and renal failure can contribute to chronic heart failure. Pancreatic disease and pulmonary insufficiency do not contribute to chronic heart failure.
Question 2 of 5
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?
Correct Answer: C
Rationale: Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.
Question 3 of 5
The nurse instructs the client with heart failure to check weight at the same time each day using the same scale. When should the client contact the health care provider?
Correct Answer: C
Rationale: Clients should check weight at the same time each day using the same scale and should consult a health care provider if the weight gain is more than 2 pounds in 24 hours. The other options are not correct since there is a variance with weight on a daily basis.
Question 4 of 5
A client with heart failure reports not having had a bowel movement in 2 days. Why would it be important for the nurse to obtain a prescription for a stool softener?
Correct Answer: A
Rationale: Avoid activities that engage the Valsalva maneuver, such as straining with bowel elimination or using the arms to pull and reposition oneself. The Valsalva maneuver increases intrathoracic pressure, reduces right atrial filling, triggers tachycardia, and increases blood pressure. The client's discomfort would be increased if hemorrhoids or a rectal fissure developed but would not engage the Valsalva maneuver. It is not necessary for the client to have a bowel movement on a daily basis.
Question 5 of 5
The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide?
Correct Answer: D
Rationale: Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These drugs increase sodium and therefore water excretion, but they also increase potassium excretion. If a client becomes hypokalemic, digitalis toxicity is more likely. The BNP does not demonstrate a severe heart failure. Sodium level of 135 is within normal range, as is the hemoglobin level.