NUR 411 chapter 32 practice questions
A 36-year-old woman with aortic stenosis
Causes of left ventricular failure include mitral or aortic valve disease, coronary artery
disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are
risk factors for right ventricular failure. A cerebral vascular accident does not increase
the risk of heart failure. - answerA nurse assesses clients on a cardiac unit. Which client
would the nurse identify as being at greatest risk for the development of left-sided heart
failure?
A 36-year-old woman with aortic stenosis
A 42-year-old man with pulmonary hypertension
A 59-year-old woman who smokes cigarettes daily
A 70-year-old man who had a cerebral vascular accident
c. "I must stop halfway up the stairs to catch my breath."
Clients with left-sided heart failure report weakness or fatigue while performing normal
activities of daily living, as well as difficulty breathing, or "catching their breath." This
occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart
failure. Thirst and blurred vision are not related to heart failure. - answerA nurse
assesses a client in an outpatient clinic. Which statement alerts the nurse to the
possibility of left-sided heart failure?
a. "I have been drinking more water than usual."
b. "I am awakened by the need to urinate at night."
c. "I must stop halfway up the stairs to catch my breath."
d. "I have experienced blurred vision on several occasions."
"My shoes fit really tight lately."
Signs of systemic congestion occur with right-sided heart failure. Fluid is retained,
pressure builds in the venous system, and peripheral edema develops. Left-sided heart
failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty
breathing all could be results of left-sided heart failure. - answerA nurse assesses a
client admitted to the cardiac unit. Which statement by the client alerts the nurse to the
possibility of right-sided heart failure?
"I sleep with four pillows at night."
"My shoes fit really tight lately."
"I wake up coughing every night."
"I have trouble catching my breath."
Assess for symptoms of left-sided heart failure.
, The presence of an S3 gallop is an early diastolic filling sound indicative of increasing
left ventricular pressure and left ventricular failure. The other actions are not warranted.
- answerWhile assessing a client on a cardiac unit, a nurse identifies the presence of an
S3 gallop. What action would the nurse take next?
Assess for symptoms of left-sided heart failure.
Document this as a normal finding.
Call the primary health care provider immediately.
Transfer the client to the intensive care unit.
"Weight is the best indication that you are gaining or losing fluid."
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid
equals 2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain.
The other responses do not address the importance of monitoring fluid retention or loss.
- answerA nurse cares for a client with right-sided heart failure. The client asks, "Why do
I need to weigh myself every day?" How would the nurse respond?
"Weight is the best indication that you are gaining or losing fluid."
"Daily weights will help us make you are eating properly."
"The hospital requires that all clients be weighed daily."
"You need to lose weight to decrease the incidence of heart failure."
"Avoid using salt substitutes."
Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion
of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be
taught to limit potassium intake. Salt substitutes are composed of potassium chloride.
ACE inhibitors do not need to be taken with food and have no impact on the client's
pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not
contraindicated. - answerA nurse is teaching a client with heart failure who has been
prescribed enalapril. Which statement would the nurse include in this client's teaching?
"Avoid using salt substitutes."
"Take your medication with food."
"Avoid using aspirin-containing products."
"Check your pulse daily."
Instruct the client to ask for assistance when rising from bed.
Hypotension is a side effect of ACE inhibitors such as captopril. Clients with a fluid
volume deficit should have their volume replaced or start at a lower dose of the drug to
minimize this
effect. The nurse would instruct the client to seek assistance before arising from bed to
prevent injury from postural hypotension. ACE inhibitors do not need to be taken with
food. Collaboration with assistive personnel to provide hygiene is not a priority. The
client would be encouraged to complete activities of daily living as independently as
possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the
A 36-year-old woman with aortic stenosis
Causes of left ventricular failure include mitral or aortic valve disease, coronary artery
disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are
risk factors for right ventricular failure. A cerebral vascular accident does not increase
the risk of heart failure. - answerA nurse assesses clients on a cardiac unit. Which client
would the nurse identify as being at greatest risk for the development of left-sided heart
failure?
A 36-year-old woman with aortic stenosis
A 42-year-old man with pulmonary hypertension
A 59-year-old woman who smokes cigarettes daily
A 70-year-old man who had a cerebral vascular accident
c. "I must stop halfway up the stairs to catch my breath."
Clients with left-sided heart failure report weakness or fatigue while performing normal
activities of daily living, as well as difficulty breathing, or "catching their breath." This
occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart
failure. Thirst and blurred vision are not related to heart failure. - answerA nurse
assesses a client in an outpatient clinic. Which statement alerts the nurse to the
possibility of left-sided heart failure?
a. "I have been drinking more water than usual."
b. "I am awakened by the need to urinate at night."
c. "I must stop halfway up the stairs to catch my breath."
d. "I have experienced blurred vision on several occasions."
"My shoes fit really tight lately."
Signs of systemic congestion occur with right-sided heart failure. Fluid is retained,
pressure builds in the venous system, and peripheral edema develops. Left-sided heart
failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty
breathing all could be results of left-sided heart failure. - answerA nurse assesses a
client admitted to the cardiac unit. Which statement by the client alerts the nurse to the
possibility of right-sided heart failure?
"I sleep with four pillows at night."
"My shoes fit really tight lately."
"I wake up coughing every night."
"I have trouble catching my breath."
Assess for symptoms of left-sided heart failure.
, The presence of an S3 gallop is an early diastolic filling sound indicative of increasing
left ventricular pressure and left ventricular failure. The other actions are not warranted.
- answerWhile assessing a client on a cardiac unit, a nurse identifies the presence of an
S3 gallop. What action would the nurse take next?
Assess for symptoms of left-sided heart failure.
Document this as a normal finding.
Call the primary health care provider immediately.
Transfer the client to the intensive care unit.
"Weight is the best indication that you are gaining or losing fluid."
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid
equals 2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain.
The other responses do not address the importance of monitoring fluid retention or loss.
- answerA nurse cares for a client with right-sided heart failure. The client asks, "Why do
I need to weigh myself every day?" How would the nurse respond?
"Weight is the best indication that you are gaining or losing fluid."
"Daily weights will help us make you are eating properly."
"The hospital requires that all clients be weighed daily."
"You need to lose weight to decrease the incidence of heart failure."
"Avoid using salt substitutes."
Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion
of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be
taught to limit potassium intake. Salt substitutes are composed of potassium chloride.
ACE inhibitors do not need to be taken with food and have no impact on the client's
pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not
contraindicated. - answerA nurse is teaching a client with heart failure who has been
prescribed enalapril. Which statement would the nurse include in this client's teaching?
"Avoid using salt substitutes."
"Take your medication with food."
"Avoid using aspirin-containing products."
"Check your pulse daily."
Instruct the client to ask for assistance when rising from bed.
Hypotension is a side effect of ACE inhibitors such as captopril. Clients with a fluid
volume deficit should have their volume replaced or start at a lower dose of the drug to
minimize this
effect. The nurse would instruct the client to seek assistance before arising from bed to
prevent injury from postural hypotension. ACE inhibitors do not need to be taken with
food. Collaboration with assistive personnel to provide hygiene is not a priority. The
client would be encouraged to complete activities of daily living as independently as
possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the
