100% COMPLETE ADULT HEALTH 2 EXAM- REVISION GUIDE 2023-2024EXAM QUESTIONS WITH DETAILED VERIFIED ANSWERS ALREADY GRADED A+
Chapter 34: Heart
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Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. While assessing a 68-yr-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient’s bed elevated 45 degrees. The nurse knows this finding indicates
a. decreased fluid volume. c. increased right atrial pressure.
b. jugular vein atherosclerosis. d. incompetent jugular vein valves.
ANS: C
The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
DIF: Cognitive Level: Understand (comprehension) REF: 739
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?
a. Weight loss of 2 lb in 24 hours
b. Hourly urine output greater than 60 mL
c. Reduction in patient complaints of chest pain
d. Reduced dyspnea with the head of bed at 30 degrees
ANS: D
Because the patient’s major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data may also indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient’s response.
DIF: Cognitive Level: Analyze (analysis) REF: 742
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
3. Which topic will the nurse plan to include in discharge teaching for a patient with heart failure with reduced ejection fraction (HFrEF)?
a. Need to begin an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Importance of making an annual appointment with the health care provider
d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
ANS: D
The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction below 40% should receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.
DIF: Cognitive Level: Apply (application) REF: 737
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
4. IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate down if the patient develops
a. ventricular ectopy. c. a systolic BP below 90 mm Hg.
b. a dry, hacking cough. d. a heart rate below 50 beats/min.
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ANS: C
Sodium nitroprusside is a potent vasodilator and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.
DIF: Cognitive Level: Apply (application) REF: 745
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
5. A patient who has chronic heart failure tells the nurse, “I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!” The nurse will document this assessment finding as
a. orthopnea. c. paroxysmal nocturnal dyspnea.
b. pulsus alternans. d. acute bilateral pleural effusion.
ANS: C
Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alteration of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.
DIF: Cognitive Level: Understand (comprehension) REF: 742
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
6. During a visit to a 78-yr-old patient with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of “feeling too tired to get out of bed.” Based on these data, a correct nursing diagnosis for [Show Less]