Heart Failure Exam Questions And Answers Updated Exam

A nurse is assessing a client with heart failure. The nurse is concerned the client is experiencing poor tissue perfusion based on which assessment findings? (Select all thatapply.) A. Capillary refill time is increasing. B. Urinary output is 20 mL/hr for the past 2 hours. C. Oxygen saturation is 93% on room air. D. Level of consciousness is decreasing. E. Blood pressure is 126/72 mmHg. - ANSWER- A, B, D Rationale: Urinary output of less than 30 mL/hr for 2 hours suggests decreased renal tissue perfusion. A blood pressure of 126/72 mmHg is within normal limits and indicates adequate tissue perfusion. An increased capillary refill time can indicate decreased cardiacoutput, which can cause poor tissue perfusion. A decreased level of consciousness indicates that the brain tissue is not being adequately perfused. An oxygen saturation of 93% is within normal limits. Therefore, there is sufficient oxygen for tissue perfusion. A nurse is reviewing diagnostic tests for a client newly diagnosed with heart failure. The nurse is concerned that the client is experiencing renal issues in addition to the heart failure. Which diagnostic tests would the nurse focus on to help determine renal function? (Select all that apply.) A. Serum creatinine B. Blood urea nitrogen (BUN) C. B-type natriuretic peptide(BNP) D. Chest x-ray E. Urinalysis - ANSWER- A, B, E Rationale: High urine pH and red blood cells are associated with renal disease. A high specific gravity can be associated with concentrated urine, which is found in clients who are retaining fluid. Creatinine is excreted by the kidneys. Serum creatinine is a better indicator of renal function than BUN. Elevated BUN can be a sign of dehydration. If the client is not dehydrated, then elevated blood urea nitrogen can be a sign of renal function. Creatinine does not elevate with dehydration. Creatinine rises when the kidneys are unable to excrete it. The chest x-ray will show enlarged heart and fluid in the lung. A chest x-ray is not diagnostic for renal problems. BNP is produced in the cardiac ventricles. It rises in response to stretch and overload. It is related to heart failure but not renal function. A nurse is providing education about heart failure to a community group. Which risk factors should the nurse include in thepresentation? (Select all thatapply.) A. Hypertension B. Diabetes mellitus C. Sleep apnea D. Coronary heart disease E. Pituitary adenoma - ANSWER- A, B, C, D Rationale: When providing education to a community group, the nurse needs to include the following risk factors for heart failure: coronary heart disease, hypertension, diabetes mellitus, and sleep apnea. Pituitary adenoma is not a risk factor for heart failure. The nurse is caring for a client newly diagnosed with heart failure. Which medication order does the nurse anticipate receiving from the healthcare provider? A. Diuretic B. Benzodiazepine C. Selective serotonin reuptake inhibitor D. Proton pump inhibitor - ANSWER- A. Rationale: Heart failure is treated with a variety of medications based on the severity and progression of disease. The nurse should anticipate an order for a diuretic. Benzodiazepine, proton pumpinhibitors, and selective serotonin reuptake inhibitors are not used to treat heart failure. A client was recently diagnosed with acute heart failure. The nurse anticipates that which cardiac disorder led to this diagnosis? A. Myocardial infarction B. Valvular disease C. Coronary heart disease D. Cardiomyopathy - ANSWER- A. Rationale Acute heart failure is a sudden decrease in cardiac function and is caused by myocardial infarction. Chronic heart failure is a gradual decrease in cardiac function. Cardiac disorders that lead to chronic heart failure include cardiomyopathy, valvular disease, and coronary heart disease.