Cardiac Disorders NCLEX

Cardiac Disorders NCLEX ScienceMedicineNursing NarsTsak Save The nurse is assessing a pt w/ chronic heart failure. Which abnormal chest sound would the nurse most likely auscultate?

• expiratory wheezes
• friction rub
• harsh vesicular
• crackles

Answer: 4

Rationale 1, 2, 3: Expiratory wheezes, friction rub, & harsh vesicular sounds are not associated w/ chronic heart failure.Rationale 4: Fluid accumulates in the alveolar spaces w/ left-sided heart failure. This fluid causes the sound of crackles at the end of inspiration.

When caring for a chronic heart failure pt w/ left-sided failure, the nurse would most likely note the following statement in the physician's written report following cardiac catheterization?

• "Pressures in the left ventricle & atrium are increased."
• "Pressures in the left ventricle & atrium are decreased."
• "Pressures in the right ventricle & atrium match the ventricle pressures."
• "Pressures in the right ventricle reflect functioning of all heart chambers."

Answer: 1

Rationale 1: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole & the chamber pressure rises due to the added blood volume.Rationale 2: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole & the chamber pressure rises due to the added blood volume.Rationale 3: This pt is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side.Rationale 4: This pt is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side.A nurse caring for a pt w/ heart failure would expect to find which of the following during assessment of the pt?

• S1, S2 & flat neck veins
• S3 & distended neck veins
• S2 is heard the loudest & followed by S1
• S4 & flat neck veins

Answer: 2

Rationale 1: S1 & S2 are normal heart sounds; flat neck veins are considered a normal finding.Rationale 2: The abnormal S3 sound is reflective of the heart's attempts to fill an already distended ventricle & the neck veins distend because of the increased venous pressure.Rationale 3: S1 & S2 sounds may be diminished in the heart failure pt & not vary in intensity.

Rationale 4: S4 (gallop) may be present but neck veins would be distended.

When obtaining the health history of a pt who is being assessed for possible congestive heart failure, it is significant when the pt says which of the following?

• "I break out in a cold sweat when I eat a large meal."
• "I am sleepy after I eat lunch each day."
• "I have to prop myself up on three pillows to sleep at night, otherwise I can't breathe."
• "I feel better w/ my legs down when I sit in my favorite chair."

Answer: 3

Rationale 1: Diaphoresis & sleepiness after meals & comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF.Rationale 2: Diaphoresis & sleepiness after meals & comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF.Rationale 3: Needing to prop oneself up w/ pillows at night in order to breathe describes orthopnea, which is consistent w/ congestive heart failure (CHF). Congestive heart failure produces a volume excess, congestion in the lungs, & dyspnea when attempting to lie down.Rationale 4: Diaphoresis & sleepiness after meals & comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF.A pt is admitted w/ acute heart failure. The nurse realizes that acute heart failure is associated w/ an abrupt onset of which of the following? Select all that apply.

• cardiomyopathy
• heart valve disease
• coronary heart disease (CHD)
• massive infarction (MI))
• myocardial injury

Correct Answer: 4,5

Rationale 1,2,3: Cardiomyopathy, valve disease, & coronary heart disease (CHD) are all associated w/ chronic heart failure.Rationale 4,5: Pts often present for care w/ signs of acute heart failure when they have had an abrupt onset of myocardial injury such as a massive myocardial infarction (MI).

Blood tests are ordered for a pt who is diagnosed w/ possible congestive heart failure (CHF).The nurse underst&s which of the following lab tests indicates heart failure? The most specific test(s) to accurately indicate CHF would be which of the following?

• liver function
• urinalysis & blood urea nitrogen (BUN)
• brain natriuretic peptide (BNF).
• serum electrolytes

Correct Answer: 3

Rationale: Liver function, urinalysis, blood urea nitrogen (BUN)), & serum electrolytes are appropriate tests for this diagnosis but brain natriuretic peptide (BNP) provides the strongest indicator. BNP have been shown to positively correlate w/ pressures in the left ventricle & pulmonary vascular system. As the severity of left ventricular failure increases, BNP levels increase.The nurse is caring for a pt who has invasive hemodynamic monitoring. The highest priority of care for this pt is which of the following?

• Prevent infection at the catheter site by changing the dressing as prescribed.
• Set alarm limits & turn monitor alarms on.
• Explain to family members why the monitoring is in use.
• Coil IV tubing on the bed.

Answer: 2

Rationale 1: Prevention of infection by changing dressings is important but not the priority of care.Rationale 2: Alarms should never be turned off as they are safety devices that warn of a disconnected line or hemodynamic instability. Alarms should always be investigated since they are suspended only when drawing blood or changing tubing.Rationale 3: Keeping family members informed about monitoring is important, but again, not the priority of care.

Rationale 4: Coiling the IV tubing on the bed is contraindicated.