Complete Test Bank | Nursing Care Of Patients With – Ch.31 - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 31 Nursing Care of Patients with Cardiac Disorders
1) The nurse is assessing a patient with chronic heart failure. Which abnormal chest sound should the nurse expect to auscultate?
1. Expiratory wheezes
2. Friction rub
3. Harsh vesicular sounds
4. Crackles
Page Ref: 1060
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
2) The nurse is caring for a chronic heart failure patient with left-sided failure. Which documentation should the nurse expect to see in the medical record after this patient has a cardiac catheterization?
1. "Pressures in the left ventricle and atrium are increased."
2. "Pressures in the left ventricle and atrium are decreased."
3. "Pressures in the right ventricle and atrium match the ventricle pressures."
4. "Pressures in the right ventricle reflect functioning of all heart chambers."
Page Ref: 1060
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation/Communication and Documentation
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
3) The nurse is caring for a patient with heart failure. What should the nurse expect when assessing this patient?
1. S1, S2, and flat neck veins
2. S3 and distended neck veins
3. S2 heard the loudest and followed by S1
4. S4 and flat neck veins
Page Ref: 1062
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
4) The nurse is obtaining the health history of a patient who is being assessed for possible heart failure (HF). Which patient statement should the nurse identify as being associated with this health problem?
1. "I break out in a cold sweat when I eat a large meal."
2. "I am sleepy after I eat lunch every day."
3. "I have to prop myself up on three pillows to sleep at night. Otherwise I can't breathe."
4. "I feel better with my legs down when I sit in my favorite chair."
Page Ref: 1060
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
5) A patient is admitted with acute heart failure. Which health problem most likely caused this new condition? Select all that apply.
1. Cardiomyopathy
2. Heart valve disease
3. Coronary heart disease (CHD)
4. Massive infarction (MI)
5. Myocardial injury
Page Ref: 1061
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
6) Blood tests are prescribed for a patient with suspected heart failure (HF). Which test result should the nurse review to support this medical diagnosis?
1. Liver function
2. Urinalysis and blood urea nitrogen (BUN)
3. Brain natriuretic peptide (BNF)
4. Serum electrolytes
Page Ref: 1061-1063
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
7) The nurse is caring for a patient who has invasive hemodynamic monitoring. What would be the highest priority of care for this patient?
1. Preventing infection at the catheter site by changing the dressing as prescribed
2. Setting alarm limits and turning monitor alarms on
3. Explaining to family members why the monitoring is in use
4. Coiling IV tubing on the bed
Page Ref: 1072
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
8) The nurse is caring for a patient in the critical care area whose fluid volume status needs to be closely assessed. Which type of monitoring should the nurse expect for this patient?
1. Arterial pressure monitoring
2. Pulmonary artery pressure monitoring
3. Central venous pressure (CVP) monitoring
4. Intra-aortic balloon pump monitoring
Page Ref: 1064
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.
9) A patient has a pulmonary artery (PA) catheter placed. What should the nurse recognize as the purpose of this catheter?
1. The patient cannot tolerate hemodynamic monitoring.
2. The patient requires a peripheral intravenous catheter for medication administration.
3. The patient would benefit from having the right ventricle pressures measured each shift.
4. The patient requires evaluation of left ventricular pressures each shift.
Page Ref: 1065
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.
10) A patient is prescribed digoxin (Lanoxin). What is the nurse's priority instruction to the patient about this medication?
1. How to manage itchy skin
2. Foods that should be eaten while taking this drug
3. The importance of not taking the medication if the pulse is under 60 beats per minute
4. The need to check the pulse once a week and record the result on a notepad
Page Ref: 1067
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
11) An older patient with chronic heart failure at home experiences an increase in pulse rate from 80 beats per minute (bpm) to 102 bpm when walking from the kitchen to the utility room to do laundry. What should the nurse encourage the patient to do?
1. Complete tasks such as laundry early in the morning before fatigue is an issue.
2. Ignore the pulse rate and become more active to build stamina.
3. Rest for 30 minutes between loads of laundry.
4. Rest on a chair in the utility room, and sit and rest when the patient feels the pulse rate increase
Page Ref: 1071
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
12) The nurse is caring for a patient with heart failure. Which finding should indicate to the nurse that the patient has decreased cardiac output and tissue perfusion?
1. Reduced mental alertness
2. Increased urine output
3. Abdominal distention
4. Strong peripheral pulses
Page Ref: 1071
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
13) A patient is exhibiting dyspnea, orthopnea, cyanosis, clammy skin, crackles, and a productive cough with pink, frothy sputum. Which health problem should the nurse suspect is occurring in this patient?
1. Chronic heart failure
2. Pulmonary edema
3. Endocarditis
4. Angina
Page Ref: 1071, 1073
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
14) A patient is diagnosed with pulmonary edema. What is a priority for this patient?
1. Inserting a peripheral intravenous catheter
2. Requesting a prescription to medicate the patient for comfort
3. Monitoring the blood glucose level
4. Placing a pulse oximeter and administering oxygen
Page Ref: 1076
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
15) The nurse is caring for a patient with possible endocarditis. What is important for the nurse to consider when caring for this patient?
1. Endocarditis does not pose a high risk of damage to affected heart valves.
2. Patients with this disorder can be treated with open heart surgery to clean the heart valves.
3. The condition is unrelated to fever, so patients can be medicated with the prescribed antipyretic and observed.
4. Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures.
Page Ref: 1081
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
16) The nurse suspects that a patient has pericarditis. What did the nurse assess to make this clinical decision? Select all that apply.
1. Pericardial friction rub
2. Abdominal discomfort and nausea
3. Chest pain
4. Bradycardia
5. Distended neck veins
Page Ref: 1077
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
17) A patient is diagnosed with cardiac tamponade. What treatment should the nurse expect to be prescribed for this patient?
1. Antidysrhythmic drugs and oxygen
2. Oxygen and rest
3. Pericardiocentesis
4. Antibiotics
Page Ref: 1087
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.
18) The nurse caring for a patient with coronary artery disease hears a murmur during auscultation of the heart. What should the nurse suspect is occurring in this patient?
1. Valvular heart disease
2. Pericarditis
3. Cardiac tamponade
4. Heart failure
Page Ref: 1090
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
19) The nurse suspects that a patient is experiencing paroxysmal nocturnal dyspnea (PND). What did the nurse assess to make this clinical decision? Select all that apply.
1. Symptoms occurring at night
2. Pulmonary congestion
3. Improving cardiac reserve
4. Voiding more than one time per night
5. Daytime peripheral edema
Page Ref: 1061
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
20) Home care teaching is being completed by the nurse for a patient recovering from rheumatic fever. Which patient statement indicates that the teaching has been effective?
1. "I will be sure to tell my dentist that I had rheumatic fever."
2. "I will try to focus on eating less protein and more fat so I will have more energy."
3. "I will avoid brushing my teeth so often and quit using mouth rinse because I have gingivitis."
4. "If my joints start to hurt again, I need to slow down, but I won't have to worry because I'm immune to rheumatic fever now."
Page Ref: 924-1079
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
21) The nurse is reviewing data collected on a group of patients. Which patient should the nurse realize is at risk for high-output heart failure?
1. A patient with chronic anemia
2. A person with untreated hypertension
3. An individual with untreated hypothyroidism
4. Someone who abuses sedatives and analgesics
Page Ref: 1061
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
22) An older patient with a history of heart failure is experiencing dyspnea, weight gain, chest pain, increasing edema of the lower extremities, and elevated blood pressure. What should the nurse ask to help determine why the patient is currently having health problems?
1. "Are you married?"
2. "Have you been out of the country lately?"
3. "Do you have grandchildren that you babysit?"
4. "Have you attended any recent family or social gatherings?"
Page Ref: 1072
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
23) The nurse is reviewing information received during hand-off communication for a group of patients. Which patient should the nurse assess first?
1. Patient with occasional chest pain who has recently been diagnosed with gallbladder disease
2. Older patient with heart failure who was admitted with increasing edema of the lower extremities
3. Newly admitted patient complaining of substernal chest pain and whose father died recently from heart disease
4. Patient complaining of chest pain and hyperventilating after a family member leaves the room following an argument
Page Ref: 1093
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
24) The nurse is caring for patients on a cardiac unit. Which patient should the nurse assess first?
1. Patient with hypertrophic cardiomyopathy who is reporting dyspnea
2. Patient who had a cardiac catheterization and will be ambulating for the first time
3. Patient receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain
4. Patient recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 101°F
Page Ref: 1081
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
25) A patient with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. What should the nurse do first?
1. Notify the physician about these findings.
2. Elevate the leg above the level of the heart.
3. Wrap the extremity in a loose, warm blanket and apply a foot cradle.
4. Perform passive range of motion (PROM) exercises to stimulate circulation.
Page Ref: 1081
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
26) A patient newly diagnosed with heart failure is prescribed 40 mg of furosemide (Lasix) to be given IV push. Knowing that the patient is also prescribed digoxin (Lanoxin), the nurse should review which laboratory result?
1. Sodium level
2. Digoxin level
3. Creatinine level
4. Potassium level
Page Ref: 1068
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
27) A patient is admitted with acute pericarditis. When auscultating heart sounds, which action should the nurse ask the patient to perform?
1. Sit and lean forward while the nurse auscultates at the left lower sternal border.
2. Lie supine and breathe quietly while the nurse auscultates for expiratory wheezes.
3. Sit upright while the nurse auscultates the outer aspects of the upper lobes for vesicular breath sounds.
4. Sit and lean forward while the nurse auscultates at the second right intercostal space, near the sternal border.
Page Ref: 1086
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.
28) A patient recovering from replacement of a mitral valve with a mechanical valve asks how long warfarin (Coumadin) needs to be taken. What is the nurse's best response?
1. "You will be on it for the rest of your life because you have a mechanical valve."
2. "That will depend on your surgeon. Ask her when you go to your office visit."
3. "You will be on it for the rest of your life because you have a biologic tissue valve."
4. "You will be told when to stop, usually when your mechanical prosthetic valve is healed and there is a minimal risk of clots."
Page Ref: 1097
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.
29) A patient is being started on enalapril (Vasotec). Which common adverse effect should the nurse review with the patient?
1. Increased thirst
2. Reduced urine output
3. Persistent cough
4. Loss of appetite
Page Ref: 1066
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
30) The nurse suspects that a patient is experiencing a neuroendocrine response from low cardiac output in heart failure. What manifestation did the nurse assess to make this clinical decision? Select all that apply.
1. Irregular heart rhythm
2. Gastrointestinal bleeding
3. Blood pressure 188/94 mmHg
4. Nausea, vomiting, and diarrhea
5. Heart rate 112 beats per minute
Page Ref: 1059
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
31) During a home visit, the nurse suspects that a patient with heart failure needs additional teaching. What did the nurse observe to make this decision? Select all that apply.
1. The patient lifted an 18-month-old child off the floor.
2. The patient's lunch was a small salad and half a sandwich.
3. The patient drank from a pitcher of water on the coffee table.
4. The patient documented the frequency and amount of walking completed.
5. Working in the kitchen, the patient was obviously sweating and short of breath.
Page Ref: 1073
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
32) The nurse is reviewing medications prescribed for a patient with myocarditis. Which medication should the nurse question before administering to the patient? Select all that apply.
1. Antibiotic
2. Anticoagulant
3. Cardiac glycoside
4. Proton pump inhibitor
5. Antidysrhythmic agent
Page Ref: 1084
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.
33) The nurse auscultates a heart murmur that is continuous and rumbling and increases in sound toward the end. Which health problem should the nurse suspect this patient might be experiencing? Select all that apply.
1. Mitral stenosis
2. Tricuspid stenosis
3. Mitral regurgitation
4. Aortic regurgitation
5. Tricuspid regurgitation
Page Ref: 1091
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
34) A patient is having diagnostic tests for aortic regurgitation. Which finding should the nurse expect to assess in this patient? Select all that apply.
1. Dizziness
2. Head bobbing
3. Peripheral edema
4. Throbbing neck pulse
5. Palpitations in the supine position
Page Ref: 1094
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.
35) A patient is scheduled for surgery to replace the mitral valve with a biologic heterograft valve. What should the nurse include when instructing the patient about this surgery? Select all that apply.
1. There will be an audible click with this valve.
2. The valve will not need to be replaced.
3. Long-term anticoagulation therapy is not necessary.
4. The valve will likely need to be replaced in 15 years.
5. Long-term antibiotic therapy is needed after the surgery.
Page Ref: 1097
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
36) The nurse is completing an assessment of a patient with hypertrophic cardiomyopathy. What intervention should the nurse identify to help this patient with feelings of fatigue? Select all that apply.
1. Organizing care to allow for rest periods
2. Restricting fluids and measuring abdominal girth
3. Reviewing dietary restrictions for sodium intake
4. Assisting with activities of daily living as needed
5. Consulting with physical therapy for an activity plan
Page Ref: 1104
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
37) A patient with rheumatic heart disease is being discharged. What should the nurse include in the patient's discharge instructions? Select all that apply.
1. "Perform dental hygiene several times a day."
2. "Complete the full course of prescribed antibiotics."
3. "Take antibiotics as prescribed before dental work."
4. "Restrict fluids and limit activity while taking medication."
5. "Notify the physician if you develop a sore throat or other infection."
Page Ref: 1079
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.
Document Information
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