Download Pretest-Chronic Heart Failure

Lewis: Medical-Surgical Nursing, 8th Edition
Chapter 35: Nursing Management: Heart Failure
Pre-Test
MULTIPLE CHOICE
1. The home care nurse visits a patient with chronic heart failure. Which clinical
manifestations,if assessed by the nurse, would indicate acute decompensated heart failure
(pulmonary edema)?
a. Fatigue, orthopnea, and dependent edema
b. Oxygen saturation at 90% and respirations 26 breaths/minute
c. Severe dyspnea and blood streaked frothy sputum
d. Temperature is 100.4o F and pulse is 102 beats/minute
ANS: C
Rationale: Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis,
clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a
respiratory rate greater than 30 breaths per minute, orthopnea, wheezing, and coughing
with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal
crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood
pressure may be elevated or decreased.
PTS: 1
2. A patient develops acute decompensated heart failure (ADHF) with severe dyspnea.
Which action by the nurse would be indicated?
a. Assist the patient to a sitting position at the bedside
b. Instruct the patient to use pursed-lip breathing
c. Restrict oral fluid intake to 500 mL per day
d. Perform a bladder scan to assess for urinary retention
ANS: A
Rationale: The nurse should place the patient with ADHF in a high Fowler’s position
with the feet horizontal in the bed or dangling at the bedside. This position helps decrease
venous return because of the pooling of blood in the extremities. This position also
increases the thoracic capacity, allowing for improved ventilation.
PTS: 1
3. A patient with chronic heart failure and atrial fibrillation asks the nurse why warfarin
(Coumadin) has been prescribed. Which response by the nurse is accurate?
a. “The medication reduces clotting factors by decreasing serum potassium levels.”
b. “The medication increases your heart rate so clots do not form in your heart.”
c. “The medication dissolves any clots that develop in your coronary arteries.”
d. “The medication prevents blood clots from forming in your heart.”
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Pre-Test
35-2
ANS: D
.
Rationale: Chronic heart failure causes enlargement of the chambers of the heart and an
altered electrical pathway especially in the atria. When numerous sites in the atria fire
spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus
formation within the atria with an increased risk of stroke and require treatment with
cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that
interferes with hepatic synthesis of vitamin K–dependent clotting factors.
PTS: 1
4. The nurse prepares to administer digoxin (Lanoxin) 0.125 mg to a patient. What should
the nurse assess before giving the medication?
a. Serum potassium level
c. Hemoglobin and hematocrit
b. Prothrombin time
d. Urine specific gravity
ANS: A
Rationale: Serum potassium should be monitored because hypokalemia increases the risk
for digoxin toxicity.
PTS: 1
5. The nurse provides dietary teaching for a patient with heart failure. The nurse determines
that teaching is successful if the patient which statement?
a. “I can add salt when preparing foods but not at the table.”
b. “I can have unlimited amounts of foods labeled as reduced sodium.”
c. “I will limit the amount of milk and cheese in my diet.”
d. “I will take my diuretic pill if my sodium intake is high.”
ANS: C
Rationale: Milk products should be limited to 2 cups per day for a 2500-mg sodiumrestricted diet. Salt should not be added during food preparation or at the table. Foods
labeled as reduced sodium contain at least 25% less sodium than regular. Diuretics should
be taken as prescribed (usually daily) and not based on sodium intake.
PTS: 1
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.