Cardiovascular System | Myocardial Infarction And Heart Failure NCLEX Quiz 18

1. Captopril may be administered to a client with HF because it acts as a:

Vasopressor

Volume expander

Vasodilator

Potassium-sparing diuretic

ACE inhibitors have become the vasodilators of choice in the client with mild to severe HF. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure.

Explanation

ACE inhibitors have become the vasodilators of choice in the client with mild to severe HF. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure.

2. The nurse finds the apical pulse below the 5th intercostal space. The nurse suspects:

Left atrial enlargement

Left ventricular enlargement

Right atrial enlargement

Right ventricular enlargement

A normal apical impulse is found under over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.

Explanation

A normal apical impulse is found under over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.

3. Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?

Risk for infection related to stasis of alveolar secretions

Impaired skin integrity related to pressure

Activity intolerance related to pump failure

Constipation related to immobility

Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue.Options A. B. and D: The client could be at risk for infection related to stasis of secretions or impaired skin integrity related to pressure. However. these are not the priority nursing diagnoses for the client with HF and pulmonary edema. nor is constipation related to immobility.

Explanation

Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue.Options A. B. and D: The client could be at risk for infection related to stasis of secretions or impaired skin integrity related to pressure. However. these are not the priority nursing diagnoses for the client with HF and pulmonary edema. nor is constipation related to immobility.

4. Which of the following is an expected outcome for a client on the second day of hospitalization after an MI?

Has severe chest pain

Can identify risks factors for MI

Agrees to participate in a cardiac rehabilitation walking program

Can perform personal self-care activities without pain

By day 2 of hospitalization after an MI. clients are expected to be able to perform personal care without chest pain. Day 2 hospitalization may be too soon for clients to be able to identify risk factors for MI or begin a walking program; however. the client may be sitting up in a chair as part of the cardiac rehabilitation program. Severe chest pain should not be present.

Explanation

By day 2 of hospitalization after an MI. clients are expected to be able to perform personal care without chest pain. Day 2 hospitalization may be too soon for clients to be able to identify risk factors for MI or begin a walking program; however. the client may be sitting up in a chair as part of the cardiac rehabilitation program. Severe chest pain should not be present.

5. Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of MI?

Liquids as ordered

Small. easily digested meals

Three regular meals per day

NPO

Recommended dietary principles in the acute phase of MI include avoiding large meals because small. easily digested foods are better digested foods are better tolerated. Fluids are given according to the client’s needs. and sodium restrictions may be prescribed. especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well.Options A and D: Clients are not prescribed a diet of liquids only or NPO unless their condition is very unstable.

Explanation

Recommended dietary principles in the acute phase of MI include avoiding large meals because small. easily digested foods are better digested foods are better tolerated. Fluids are given according to the client’s needs. and sodium restrictions may be prescribed. especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well.Options A and D: Clients are not prescribed a diet of liquids only or NPO unless their condition is very unstable.

6. An older. sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:

Left ventricular atrophy

Irregular heartbeats

Peripheral vascular occlusion

Pacemaker placement

In older adults who are less active and do not exercise the heart muscle. atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result. under sudden emotional or physical stress. the left ventricle is less able to respond to the increased demands on the myocardial muscle.

Explanation

In older adults who are less active and do not exercise the heart muscle. atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result. under sudden emotional or physical stress. the left ventricle is less able to respond to the increased demands on the myocardial muscle.

7. Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet?

Apples

Tomato juice

Whole wheat bread

Beef tenderloin

Canned foods and juices. such as tomato juice. are typically high in sodium and should be avoided on a sodium-restricted diet.

Explanation

Canned foods and juices. such as tomato juice. are typically high in sodium and should be avoided on a sodium-restricted diet.

8. Furosemide is administered intravenously to a client with HF. How soon after administration should the nurse begin to see evidence of the drugs desired effect?

5 to 10 minutes

30 to 60 minutes

2 to 4 hours

6 to 8 hours

After IV injection of furosemide. diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours.

Explanation

After IV injection of furosemide. diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours.

9. Which of the following arteries primarily feeds the anterior wall of the heart?

Circumflex artery

Internal mammary artery

Left anterior descending artery

Right coronary artery

The left anterior descending artery is the primary source of blood for the anterior wall of the heart.Options A. B. and D: The circumflex artery supplies the lateral wall. the internal mammary artery supplies the mammary. and the right coronary artery supplies the inferior wall of the heart.

Explanation

The left anterior descending artery is the primary source of blood for the anterior wall of the heart.Options A. B. and D: The circumflex artery supplies the lateral wall. the internal mammary artery supplies the mammary. and the right coronary artery supplies the inferior wall of the heart.

10. Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.

Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.

Activity intolerance related to increased cardiac output.

Decreased cardiac output related to structural and functional changes.

Impaired gas exchange related to decreased sympathetic nervous system activity.

HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result. blood pools in the left ventricle and backs up into the left atrium. and eventually into the lungs. Therefore. greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition. this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically. these clients have an ejection fraction of less than 50% and poorly tolerate activity.Option B: Activity intolerance is related to a decrease. not increase. in cardiac output.Option D: Gas exchange is impaired. However. the decrease in cardiac output triggers compensatory mechanisms. such as an increase in sympathetic nervous system activity.

Explanation

HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result. blood pools in the left ventricle and backs up into the left atrium. and eventually into the lungs. Therefore. greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition. this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically. these clients have an ejection fraction of less than 50% and poorly tolerate activity.Option B: Activity intolerance is related to a decrease. not increase. in cardiac output.Option D: Gas exchange is impaired. However. the decrease in cardiac output triggers compensatory mechanisms. such as an increase in sympathetic nervous system activity.

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