Question 1

The nurse is caring for a patient who has invasive hemodynamic monitoring. What would be the highest priority of care for this patient?

Accepted Answer

Setting alarm limits and turning monitor alarms on is the highest priority because it ensures immediate detection of any critical changes in the patient's hemodynamic status, which is crucial for timely intervention and patient safety.

Question 2

A patient is diagnosed with cardiac tamponade. What treatment should the nurse expect to be prescribed for this patient?

Accepted Answer

Cardiac tamponade is a medical emergency that requires prompt intervention. The most appropriate treatment for cardiac tamponade is pericardiocentesis, which involves the removal of fluid from the pericardial sac using a needle or catheter. Antidysrhythmic drugs and oxygen may be necessary to manage complications of cardiac tamponade, but they would not be the primary treatment. Rest and antibiotics would not be effective treatments for cardiac tamponade.

Question 3

The nurse is caring for a patient with possible endocarditis. What is important for the nurse to consider when caring for this patient?

Accepted Answer

Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures. Other options are incorrect as endocarditis can pose a high risk of damage to affected heart valves, open heart surgery may not be necessary, and fever is a common symptom of endocarditis that should be treated along with the underlying infection.

Question 4

Blood tests are ordered for a patient with suspected heart failure (HF). Which test result should the nurse review to support this medical diagnosis?

Accepted Answer

Brain natriuretic peptide (BNF) is released by the heart in response to increased pressure or volume overload, which are hallmark features of heart failure. Elevated levels of BNF can support the medical diagnosis of heart failure. The other options may be ordered for various reasons in a patient with heart failure, but would not be definitive in supporting the diagnosis of HF.

Question 5

The nurse is assessing a patient with chronic heart failure. Which abnormal chest sound should the nurse expect to auscultate?

Accepted Answer

Crackles are the abnormal chest sound that the nurse should expect to auscultate in a patient with chronic heart failure. Crackles are caused by fluid accumulation in the alveoli, which is a common symptom of heart failure. Expiratory wheezes are associated with respiratory conditions such as asthma, while a friction rub suggests inflammation of the pleura. Harsh vesicular sounds are within normal limits.

Question 6

An older patient was recently discharged to home after treatment for chronic heart failure. The patient experiences an increase in pulse rate from 80 beats per minute (bpm) to 102 bpm when walking from the kitchen to the utility room to do laundry. What should the home care nurse encourage the patient to do?

Accepted Answer

The nurse should encourage the patient to rest on a chair in the utility room and to sit and rest when the pulse rate increases. This will help the patient manage the symptoms of chronic heart failure and reduce the risk of further complications. The nurse should also encourage the patient to avoid tasks that require a lot of physical exertion and to rest between activities. The other options are not appropriate as they either ignore the symptoms or do not provide adequate support for the patient.

Question 7

The nurse is caring for a patient in the critical care area whose fluid volume status needs to be closely assessed. Which type of monitoring should the nurse expect for this patient?

Accepted Answer

Central venous pressure (CVP) monitoring is the best choice for assessing fluid volume status. CVP reflects the pressure in the vena cava which is an indirect reflection of the patient's intra-vascular volume. Arterial pressure monitoring reflects the patient's blood pressure but does not provide information specific to fluid volume status. Pulmonary artery pressure monitoring is useful in assessing cardiac function but is invasive and not specific to fluid volume status. Intra-aortic balloon pump monitoring is used for patients with severe heart failure or cardiogenic shock, and it does not assess fluid volume status.

Question 8

A patient in the critical care area has an invasive hemodynamic pressure monitoring line. This position should be marked on the chest wall as a consistent reference point for calibrating and leveling. Indicate on the diagram where the chest should be marked by placing an "X" at the appropriate reference point.

Accepted Answer

The answer of A patient in the critical care area...

Question 9

The nurse suspects that a patient is experiencing paroxysmal nocturnal dyspnea (PND). What did the nurse assess to make this clinical decision?

Accepted Answer

The answer of The nurse suspects that a patient is...

Question 10

The nurse should recognize which finding as a sign of decreased cardiac output and tissue perfusion in a patient with heart failure?

Accepted Answer

Reduced mental alertness is a sign of decreased perfusion to the brain, which can occur in heart failure due to decreased cardiac output.

Question 11

The nurse caring for a patient with coronary artery disease hears a murmur during auscultation of the heart. What should the nurse suspect is occurring in this patient?

Accepted Answer

A murmur during auscultation of the heart may indicate valvular heart disease, which is a condition that affects the valves of the heart and can cause stenosis, regurgitation or prolapse. Other conditions such as pericarditis, cardiac tamponade, and heart failure may have different signs and symptoms during assessment.

Question 12

The nurse suspects that a patient has pericarditis. What did the nurse assess to make this clinical decision?

Accepted Answer

Pericarditis is inflammation of the pericardium, the sac around the heart. The classic symptom of pericarditis is chest pain, which is usually sharp and worsens when lying down or taking a deep breath. A pericardial friction rub, a specific type of heart sound, may also be heard on auscultation, which confirms the diagnosis. Abdominal discomfort, nausea, bradycardia, and distended neck veins are not typical symptoms of pericarditis.

Question 13

The nurse is caring for a chronic heart failure patient with left-sided failure. Which documentation should the nurse expect to see in the medical record after this patient has a cardiac catheterization?

Accepted Answer

In left-sided heart failure, the left ventricle and atrium are unable to effectively pump blood out to the body, leading to increased pressures in these chambers. Cardiac catheterization can measure these pressures, confirming the diagnosis.

Question 14

The nurse is obtaining the health history of a patient who is being assessed for possible heart failure (HF). Which patient statement should the nurse identify as being associated with this condition?

Accepted Answer

The patient's statement about needing to prop themselves up on pillows to breathe at night is associated with heart failure, as it can be a sign of pulmonary congestion. Choices A, B, and D are not specific to heart failure and could be related to other conditions or factors.

Question 15

A patient is diagnosed with pulmonary edema. What is a priority for this patient?

Accepted Answer

Pulmonary edema is a medical emergency that requires prompt intervention to reduce the risk of respiratory failure and cardiopulmonary arrest. Placing a pulse oximeter and administering supplemental oxygen is a priority to improve oxygenation and reduce the workload on the heart. The other options are important but do not address the immediate needs of the patient.

Question 16

A patient is prescribed digoxin (Lanoxin). What is the nurse's priority instruction to the patient about this medication?

Accepted Answer

The priority instruction to the patient about digoxin is the importance of not taking the medication if the pulse is under 60 beats per minute. Digoxin can cause arrhythmias and slowing of the heart rate, and taking it when the pulse is already low can be dangerous. Itchy skin and dietary restrictions may be relevant instructions, but not the priority. Checking the pulse once a week and recording the result is a good self-monitoring practice, but not as important as not taking the medication when the pulse is low.

Question 17

The nurse is caring for a patient with heart failure. What should the nurse expect when assessing this patient?

Accepted Answer

When assessing a patient with heart failure, the nurse should expect to hear an S3 sound and see distended neck veins, as these are signs of elevated fluid volume in the heart and blood vessels. S1 and S2 sounds may still be present, but may be softer or harder to hear depending on the severity of heart failure. S4 sounds and flat neck veins are not typically associated with heart failure.

Question 18

A patient has a pulmonary artery (PA) catheter placed. What should the nurse recognize as the purpose of this catheter?

Accepted Answer

A pulmonary artery catheter is used to measure pressures in the left side of the heart, including left ventricular pressures, to assess cardiac function and fluid status.

Question 19

A patient is admitted with acute heart failure. The nurse recognizes that this condition is associated with an abrupt onset of which health problems?

Accepted Answer

The answer of A patient is admitted with acute heart...

Question 20

A patient is exhibiting dyspnea, orthopnea, cyanosis, clammy skin, crackles, and a productive cough with pink, frothy sputum. Which health problem should the nurse suspect is occurring in this patient?

Accepted Answer

The combination of dyspnea, orthopnea, cyanosis, clammy skin, crackles, and a productive cough with pink, frothy sputum is indicative of pulmonary edema, which is a buildup of fluid in the lungs commonly seen in patients with chronic heart failure. Endocarditis is an infection of the heart valves, and angina is a type of chest pain caused by reduced blood flow to the heart. While these conditions may cause some of the symptoms mentioned, they do not fit the full picture presented in the question.

Quiz 31: Nursing Care of Patients With Cardiac Disorders