Chapter 35 Nursing Management Heart Failure
Chapter 35: Nursing Management: Heart Failure
Test Bank
MULTIPLE CHOICE
1. While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention
(JVD) with the head of the patient’s bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume.
b. jugular vein atherosclerosis.
c. increased right atrial pressure.
d. incompetent jugular vein valves.
ANS: C
The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
DIF: Cognitive Level: Understand (comprehension)
REF: 769
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the
treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?
a. Weight loss of 2 pounds in 24 hours
b. Hourly urine output greater than 60 mL
c. Reduction in patient complaints of chest pain
d. Reduced dyspnea with the head of bed at 30 degrees
ANS: D
Because the patient’s major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patient’s response.
DIF: Cognitive Level: Apply (application)
REF:
769-770 | 773-774
TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
3. Which topic will the nurse plan to include in discharge teaching for a patient with systolic
heart failure and an
Test Bank
MULTIPLE CHOICE
1. While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention
(JVD) with the head of the patient’s bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume.
b. jugular vein atherosclerosis.
c. increased right atrial pressure.
d. incompetent jugular vein valves.
ANS: C
The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
DIF: Cognitive Level: Understand (comprehension)
REF: 769
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the
treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?
a. Weight loss of 2 pounds in 24 hours
b. Hourly urine output greater than 60 mL
c. Reduction in patient complaints of chest pain
d. Reduced dyspnea with the head of bed at 30 degrees
ANS: D
Because the patient’s major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patient’s response.
DIF: Cognitive Level: Apply (application)
REF:
769-770 | 773-774
TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
3. Which topic will the nurse plan to include in discharge teaching for a patient with systolic
heart failure and an