A client with acute heart failure is sitting up in bed with respiratory rate of 28, cyanosis and is using accessory muscles. Unable to speak due to the dyspnea. She nods her head ‘yes’ when asked if she is short of breath. What action should the nurse perform first?

Check MAR for antianxiety medication

Ask when the dyspnea started

Notify the provider

Increase oxygen from 3L/minute to 5L/minute

Answer and Explanation

The Correct Answer is D

In this scenario, the client is exhibiting signs of severe respiratory distress, which could indicate worsening acute heart failure and potential respiratory failure.

a. Check MAR for antianxiety medication: While anxiety may exacerbate the client's symptoms, the priority at this moment is to address the acute respiratory distress and ensure adequate oxygenation. Checking the medication administration record (MAR) for antianxiety medication can be done later but is not the immediate priority.

b. Ask when the dyspnea started: While obtaining a thorough history is important for understanding the onset and progression of the client's symptoms, it is not the first action to take in this critical situation. The client's current condition requires immediate intervention to ensure adequate oxygenation and stabilization.

c. Notify the provider: Notifying the provider is important, especially in a situation where the client's condition is deteriorating rapidly. However, this action may take some time, and the priority is to address the client's immediate needs first.

d. Increase oxygen from 3L/minute to 5L/minute: This is the most appropriate action to take first. The client is showing signs of severe respiratory distress with cyanosis and increased work of breathing. Increasing the oxygen flow rate from 3L/minute to 5L/minute can help improve oxygenation and alleviate hypoxemia, which is crucial in the management of acute heart failure exacerbation.

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Correct Answer is B

Explanation

a. Hemolytic anemia: Hemolytic anemia is more commonly associated with mechanical heart valves rather than tissue valves. Mechanical valves can cause damage to red blood cells as they move through the valve, leading to hemolysis and subsequent anemia. Tissue valves typically do not cause significant hemolysis.

b. Endocarditis: Endocarditis is a known complication associated with prosthetic heart valves, including tissue valves. While tissue valves generally have a lower risk of thrombosis compared to mechanical valves, they are still susceptible to bacterial colonization and subsequent endocarditis. Patients with prosthetic heart valves, regardless of type, are recommended to take antibiotic prophylaxis before certain dental or surgical procedures to reduce the risk of infective endocarditis

c. Hypertension: Hypertension is not specifically associated with tissue valve replacements. While hypertension is a common cardiovascular condition, it is not directly related to the type of prosthetic valve implanted.

d. Elevated PT/INR: Elevated prothrombin time (PT) and international normalized ratio (INR) are more commonly associated with mechanical heart valves rather than tissue valves. Mechanical valves require lifelong anticoagulation therapy with medications such as warfarin to prevent thrombosis. Tissue valves generally do not require long-term anticoagulation therapy, although they may still require short-term anticoagulation immediately after implantation.

A. Bloody sputum B. Peripheral edema C. Dyspnea on exertion D. Angina E. Syncope

Correct Answer is ["C","D","E"]

Explanation

a. Bloody sputum: Bloody sputum is not typically associated with aortic stenosis. It may be indicative of other conditions such as pulmonary embolism, pneumonia, or bronchitis, but it is not a common symptom of aortic stenosis. Therefore, this symptom is not anticipated.

b. Peripheral edema: Peripheral edema is not a common symptom of isolated aortic stenosis. It is more commonly associated with conditions such as heart failure, where fluid retention leads to swelling in the extremities. Therefore, peripheral edema is not typically anticipated in aortic stenosis.

c. Dyspnea on exertion: Dyspnea on exertion is a classic symptom of aortic stenosis. It occurs due to the narrowing of the aortic valve, which leads to increased resistance to blood flow from the left ventricle to the aorta during physical activity. This can result in breathlessness and difficulty breathing during exertion.

d. Angina: Angina, or chest pain, is a common symptom of aortic stenosis, especially in cases where there is concurrent coronary artery disease (CAD). Aortic stenosis can increase myocardial oxygen demand, leading to ischemia and chest pain, particularly during exertion.

e. Syncope: Syncope, or fainting, is a serious symptom of aortic stenosis and indicates severe disease. It typically occurs due to decreased cardiac output during exertion, leading to inadequate cerebral perfusion. Syncope in aortic stenosis is often exertional and may occur with activities such as exercise or even just walking.

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A client with acute heart failure is sitting up in bed with respiratory rate of 28, cyanosis and is using accessory muscles. Unable to speak due to the dyspnea. She nods her head ‘yes’ when asked if she is short of breath. What action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has received a tissue valve replacement for treatment of valve disease. Which complication occurs more often with this type of prosthetic valve?

Correct Answer is B

Explanation

When taking a health history of a client with suspected aortic stenosis, which symptoms would the nurse anticipate? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

The nurse is preparing discharge teaching for a client following placement of a mechanical aortic valve. Which information regarding warfarin(coumadin) therapy would the nurse include? Select all that apply.

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A client with mitral stenosis has now developed atrial fibrillation. Which drug would the nurse anticipate being ordered to manage this new condition?

A client is admitted for treatment of pulmonary edema. Which medication will the nurse administer to improve the force of cardiac contraction for this client?

A client with heart failure is scheduled to receive 40 mg of Furosemide IV push. Which data would cause the nurse to question administering this medication?

The nurse is admitting a client with COPD and respiratory acidosis. Which assessment finding would the nurse anticipate for this client?

The nurse is reviewing data of a client in acute heart failure who is receiving hydralazine IV push. Which is the therapeutic effect of this medication?

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