Question 1

The nurse is contributing to a plan of care for a patient who has had a 5 pound weight gain in 2 days,pitting edema of the ankles,lung crackles,and distended neck veins.Which nursing diagnosis would be given priority in the plan of care?

Accepted Answer

The manifestations observed indicate excess fluid volume.A.B.D.The manifestations do not support noncompliance,urinary retention,or ineffective health maintenance.

Question 2

A patient with increased dyspnea has bilateral crackles on auscultation.Which action should the nurse take?

Accepted Answer

High Fowler's position aids breathing as the lungs can more easily expand the higher upright the patient sits.A.Placing the patient in an optimal position would be the first priority.Then the RN should be notified.B.Lying on the right side will not improve oxygenation.D.The patient does not need to be instructed on the use of oral suctioning.

Question 3

A patient who is to receive bumetanide (Bumex)in 1 hour has less ankle edema and neck vein distention than earlier.What action should the nurse take?

Accepted Answer

The nurse should give the medication as prescribed since the desired effect is to reduce ankle edema and prevent it from occurring.A.B.C.There is no reason to hold the medication,give it early,or to notify the RN.

Question 4

The nurse is contributing to a plan of care for a patient who has heart failure.What should be the major goal of nursing management for this patient?

Accepted Answer

Reducing the workload of the heart is the major goal for the patient with heart failure.A.Fluid overload is a manifestation of heart failure.C.Venous return needs to be promoted.D.A decrease in cardiac output would increase the patient's symptoms.

Question 5

A patient with a potassium level of 3 mEq/L is to receive furosemide (Lasix)20 mg by mouth.What action should the nurse take?

Accepted Answer

Furosemide (Lasix)is a potassium-wasting diuretic.The potassium level is low,so the Lasix should not be given,and the RN or physician should be notified of the potassium level for further orders.A.B.D.These actions should not be done before consulting with the RN.

Question 6

The nurse is assisting with the care of a patient who is experiencing pulmonary edema.Which finding should the nurse expect to observe?

Accepted Answer

Pink,frothy sputum is the classic symptom of pulmonary edema.A.B.C.These are systemic symptoms of heart failure.

Question 7

A patient is receiving digoxin (Lanoxin)daily.Which symptom should the nurse report for follow-up related to the digoxin?

Accepted Answer

Anorexia is a symptom of digoxin toxicity.A digoxin level should be done and digoxin held until the results are reviewed by the physician.B.C.D.These findings do not indicate digoxin toxicity.

Question 8

A patient has been given bumetanide (Bumex)3 mg intravenously.Which action should the nurse take after this medication is administered?

Accepted Answer

Bumetanide (Bumex)is a diuretic; the nurse should monitor urine output.B.The patient's weight is not going to reflect the effects of the medication within 2 hours.C.This medication does not cause cardiac dysrhythmias.D.Leg cramps should be reported.

Question 9

The nurse is collecting data from a patient who is receiving digoxin (Lanoxin),0.125 mg daily.Which finding should indicate to the nurse that the patient is experiencing side effects of the medication?

Accepted Answer

Bradycardia is an adverse effect of digoxin.The apical pulse is taken for 1 minute prior to administration.B.C.D.These are not adverse effects of digoxin.

Question 10

The nurse is collecting data from a patient who is in left-sided heart failure.Which finding should the nurse identify as being consistent with this diagnosis?

Accepted Answer

Left-sided heart failure symptoms include lung symptoms such as dyspnea and cough.B.C.D.These findings are more common with right-sided heart failure.

Question 11

A patient with heart failure has clavicle muscle retractions,nostril flaring,and labored breathing.Vital signs are: blood pressure 162/84 mm Hg,pulse 120 beats/min,and respirations 32/min.Which patient data requires immediate action?

Accepted Answer

As the body is less able to compensate for decreased cardiac output,respirations will slow and become shallow.This patient is in serious difficulty and would need immediate treatment to survive.B.C.D.These are signs of the body working to compensate and provide more oxygen.

Question 12

The nurse provides morphine as prescribed to a patient experiencing anxiety,dyspnea,diaphoresis; retractions; pink,frothy sputum; blood pressure 174/86 mm Hg; pulse 116 beats/min; and respirations 32/min.Which finding should the nurse consider as desirable after receiving the morphine?

Accepted Answer

Morphine reduces preload,afterload,and anxiety.Reduced blood pressure reflects a desired effect of the morphine.A.C.D.These are undesired effects from the morphine.

Question 13

A patient is receiving potassium (K-Lor)20 mEq/L,furosemide (Lasix)20 mg,and digoxin (Lanoxin)0.125 mg orally.The patient's potassium level is 5.8 mEq/L and the dose of K-Lor 10 mEq/L is scheduled to be given now.What action should the nurse take?

Accepted Answer

The nurse should not give the K-Lor as the potassium is too high and giving more could have serious effects for the patient.The assessments listed do not clarify the patient's condition or address hyperkalemia.A.C.These actions do not support the patient's elevated potassium level.B.Giving the dose of potassium could be harmful and lead to adverse effects in the patient.

Question 14

The nurse is caring for a patient who is prescribed furosemide (Lasix).Which laboratory result should the nurse review first?

Accepted Answer

Furosemide (Lasix)is a potassium-wasting diuretic.It is essential to monitor and review potassium levels before administering the Lasix,and if the level is too low,it should be held and the RN or physician notified.A.B.It is not necessary to review urine or serum sodium levels.C.A urine potassium level might not be available.

Question 15

A patient is receiving potassium (K-Lor)20 mEq/L,furosemide (Lasix)20 mg,and digoxin (Lanoxin)0.125 mg orally.The patient's potassium level is 4 mEq/L and urine output for the last 8 hours was 350 mL.What should the nurse do about the prescribed medications?

Accepted Answer

The nurse should give the medications as scheduled now.The patient has some urine output but needs the medications to increase it.The patient needs the diuretic to remove fluid and the potassium to balance potassium loss.The digoxin will help improve cardiac output by strengthening heart contractions.A.There is no reason to inform the RN.B.D.There is no reason to hold the Lasix or Lanoxin.

Question 16

A patient with heart failure is prescribed bedrest however becomes angry and walks to the bathroom independently to use the commode.How should the nurse handle this situation?

Accepted Answer

A bedside commode can ensure for the patient's safety,puts less strain on the heart than using a bedpan,and maintains the bedrest order B.This action would not support the order for bedrest.C.A bedpan puts strain on the heart.D.The nurse cannot restrain the patient in bed.

Question 17

A patient is taking bumetanide (Bumex).What is the most important for the nurse to monitor in this patient?

Accepted Answer

Hypokalemia can occur with bumetanide (potassium-wasting diuretic),which is why potassium levels are monitored before administration of the medication.Mild hypokalemia is often asymptomatic but can cause a rise in blood pressure or cardiac dysrhythmias.Moderate hypokalemia can cause muscle weakness,muscle cramping,and constipation.A.A change in skin turgor could indicate dehydration however this is not the most important for the nurse to monitor in this patient.B.C.These findings do not indicate an adverse effect of the medication.

Question 18

During a visit to the home of a patient with heart failure and diabetes the nurse learns that the patient "feels strange." Data collected includes blood pressure 172/94 mm Hg,pulse 112 beats/min,respirations 22/min; heart rhythm regular; coarse crackles in lower lung bases.What action should the nurse take?

Accepted Answer

The RN or supervisor should be consulted immediately so that the patient's symptoms of heart failure which could progress to pulmonary edema can be treated.The physician will then be contacted for treatment orders.B.There is no evidence that orange juice is needed.C.D.There is no evidence that the patient is fatigued and waiting to reassess vital signs in 30 minutes could be dangerous for the patient.

Question 19

A patient is diagnosed with a heart problem that affects preload.How should the nurse describe preload to the patient?

Accepted Answer

The fluid volume returning to the heart (preload)causes stretch in ventricles before systole.The more fluid there is,the greater the stretch can be.A.C.D.These statements do not describe preload.

Question 20

A patient is receiving potassium (K-Lor)10 mEq/L,bumetanide (Bumex)20 mg,and digoxin (Lanoxin)0.125 mg orally.The patient's morning potassium level is 4.2 mEq/L and the dose of K-Lor 10 mEq/L is scheduled to be given now.What action should the nurse take?

Accepted Answer

The nurse should give the K-Lor as scheduled now.The patient is on a potassium-wasting diuretic,Bumex,but the potassium level is within normal limits due to the potassium supplement,so it is important to continue to give the K-Lor now.A.There is no reason to hold the K-Lor.B.There is nothing significant to report to the RN.C.There is no evidence to support holding the next dose of digoxin.

Quiz 26: Nursing Care of Patients With Heart Failure

The nurse is contributing to a plan of care for a patient who has had a 5 pound weight gain in 2 days,pitting edema of the ankles,lung crackles,and distended neck veins.Which nursing diagnosis would be given priority in the plan of care?

A patient with increased dyspnea has bilateral crackles on auscultation.Which action should the nurse take?

A patient who is to receive bumetanide (Bumex) in 1 hour has less ankle edema and neck vein distention than earlier.What action should the nurse take?

The nurse is contributing to a plan of care for a patient who has heart failure.What should be the major goal of nursing management for this patient?

A patient with a potassium level of 3 mEq/L is to receive furosemide (Lasix) 20 mg by mouth.What action should the nurse take?

The nurse is assisting with the care of a patient who is experiencing pulmonary edema.Which finding should the nurse expect to observe?

A patient is receiving digoxin (Lanoxin) daily.Which symptom should the nurse report for follow-up related to the digoxin?

A patient has been given bumetanide (Bumex) 3 mg intravenously.Which action should the nurse take after this medication is administered?

The nurse is collecting data from a patient who is receiving digoxin (Lanoxin) ,0.125 mg daily.Which finding should indicate to the nurse that the patient is experiencing side effects of the medication?

The nurse is collecting data from a patient who is in left-sided heart failure.Which finding should the nurse identify as being consistent with this diagnosis?

A patient with heart failure has clavicle muscle retractions,nostril flaring,and labored breathing.Vital signs are: blood pressure 162/84 mm Hg,pulse 120 beats/min,and respirations 32/min.Which patient data requires immediate action?

The nurse provides morphine as prescribed to a patient experiencing anxiety,dyspnea,diaphoresis; retractions; pink,frothy sputum; blood pressure 174/86 mm Hg; pulse 116 beats/min; and respirations 32/min.Which finding should the nurse consider as desirable after receiving the morphine?

A patient is receiving potassium (K-Lor) 20 mEq/L,furosemide (Lasix) 20 mg,and digoxin (Lanoxin) 0.125 mg orally.The patient's potassium level is 5.8 mEq/L and the dose of K-Lor 10 mEq/L is scheduled to be given now.What action should the nurse take?

The nurse is caring for a patient who is prescribed furosemide (Lasix) .Which laboratory result should the nurse review first?

A patient is receiving potassium (K-Lor) 20 mEq/L,furosemide (Lasix) 20 mg,and digoxin (Lanoxin) 0.125 mg orally.The patient's potassium level is 4 mEq/L and urine output for the last 8 hours was 350 mL.What should the nurse do about the prescribed medications?

A patient with heart failure is prescribed bedrest however becomes angry and walks to the bathroom independently to use the commode.How should the nurse handle this situation?

A patient is taking bumetanide (Bumex) .What is the most important for the nurse to monitor in this patient?

A patient is diagnosed with a heart problem that affects preload.How should the nurse describe preload to the patient?

A patient is receiving potassium (K-Lor) 10 mEq/L,bumetanide (Bumex) 20 mg,and digoxin (Lanoxin) 0.125 mg orally.The patient's morning potassium level is 4.2 mEq/L and the dose of K-Lor 10 mEq/L is scheduled to be given now.What action should the nurse take?