31 Nursing Care of Patients with Cardiac Disorders

Directory NCLEX-RN® REVIEW Test Questions Lecture Note Presentation

NCLEX-RN® REVIEW Test Questions

NCLEX-RN® REVIEW Test Question 1 In reviewing the physician’s admitting notes for a patient with heart failure, the nurse notes that the patient has an ejection fraction of 25%. The nurse recognizes this as meaning which of the following?

NCLEX-RN® REVIEW Test Question 1 Choices Ventricular function is severely impaired. The amount of blood being ejected from the ventricles is within normal limits. Twenty-five percent of the blood entering the ventricle remains in the ventricle after systole. Cardiac output is greater than normal, overtaxing the heart. 5

NCLEX-RN® REVIEW Test Question 1 Response Ventricular function is severely impaired. The amount of blood being ejected from the ventricles is within normal limits. Twenty-five percent of the blood entering the ventricle remains in the ventricle after systole. Cardiac output is greater than normal, overtaxing the heart.

NCLEX-RN® REVIEW Test Question 1 Rationale Normal ejection fraction is 60%; an ejection fraction of 25% indicates severe impairment of ventricular function.

NCLEX-RN® REVIEW Test Question 2 In assessing a patient admitted 24 hours previously with heart failure, the nurse notes that the patient has lost 2.5 lb (1 kg) of weight, his heart rate is 88 (HR was 105 on admission), and he now has crackles in the bases of his lung fields only. The nurse correctly interprets this data as indicating which of the following?

NCLEX-RN® REVIEW Test Question 2 Choices The patient’s condition is unchanged from admission. More aggressive treatment is needed. The treatment regimen is achieving the desired effect. No further treatment is required at this time as the failure has resolved. 9

NCLEX-RN® REVIEW Test Question 2 Response The patient’s condition is unchanged from admission. More aggressive treatment is needed. The treatment regimen is achieving the desired effect. No further treatment is required at this time as the failure has resolved.

NCLEX-RN® REVIEW Test Question 2 Rationale Interdisciplinary treatment goals for the patient with heart failure are to reduce the cardiac workload and improve pump effectiveness. Loss of excess fluid, as indicated by weight loss, reduces cardiac work. The drop in heart rate and reduced pulmonary vascular congestion are indicative of improved cardiac pump.

NCLEX-RN® REVIEW Test Question 3 The nurse assessing a patient admitted with left ventricular failure would recognize which of the following findings as consistent with the diagnosis? Select all that apply. 5 cm jugular vein distention at 30° complaints of shortness of breath with minimal exertion substernal chest pain during exercise bilateral inspiratory crackles to midscapulae fatigue

NCLEX-RN® REVIEW Test Question 3 Response The nurse assessing a patient admitted with left ventricular failure would recognize which of the following findings as consistent with the diagnosis? Select all that apply. 5 cm jugular vein distention at 30° complaints of shortness of breath with minimal exertion substernal chest pain during exercise bilateral inspiratory crackles to midscapulae fatigue

NCLEX-RN® REVIEW Test Question 3 Rationale In left ventricular failure, the cardiac output falls and pressure in the pulmonary vascular system increases. This leads to fatigue, increasing dyspnea, and crackles in the lung bases.

NCLEX-RN® REVIEW Test Question 4 The nurse caring for a patient undergoing pulmonary artery pressure monitoring provides appropriate care when he or she does which of the following? secures the intravenous line to the bed linens maintains flush solution flow by gravity reports waveform dampening during wedge pressure measurements calibrates and levels the system every shift

NCLEX-RN® REVIEW Test Question 4 Response The nurse caring for a patient undergoing pulmonary artery pressure monitoring provides appropriate care when he or she does which of the following? secures the intravenous line to the bed linens maintains flush solution flow by gravity reports waveform dampening during wedge pressure measurements calibrates and levels the system every shift

NCLEX-RN® REVIEW Test Question 4 Rationale Calibrating and leveling the system during each shift ensures accuracy and consistency of measurements.

NCLEX-RN® REVIEW Test Question 5 Morphine 2 to 5 mg IV as needed for pain and dyspnea is ordered for a patient in acute pulmonary edema. The nurse appropriately does which of the following?

NCLEX-RN® REVIEW Test Question 5 Choices questions this order because no time intervals have been specified administers the drug as ordered, monitoring respiratory status withholds the drug until the patient’s respiratory status improves administers the drug only when the patient complains of chest pain 19

NCLEX-RN® REVIEW Test Question 5 Response questions this order because no time intervals have been specified administers the drug as ordered, monitoring respiratory status withholds the drug until the patient’s respiratory status improves administers the drug only when the patient complains of chest pain

NCLEX-RN® REVIEW Test Question 5 Rationale Morphine is given intravenously to relieve anxiety; it also is a venous vasodilator, reducing venous return and cardiac work.

NCLEX-RN® REVIEW Test Question 6 The nurse notes a grating heart sound when auscultating the apical pulse of a patient with pericarditis. The most appropriate response is to do which of the following? Note the finding in the patient’s medical record. Obtain an electrocardiogram. Immediately notify the physician. Initiate resuscitation measures.

NCLEX-RN® REVIEW Test Question 6 Response The nurse notes a grating heart sound when auscultating the apical pulse of a patient with pericarditis. The most appropriate response is to do which of the following? Note the finding in the patient’s medical record. Obtain an electrocardiogram. Immediately notify the physician. Initiate resuscitation measures.

NCLEX-RN® REVIEW Test Question 6 Rationale A pericardial friction rub, a grating sound, is a characteristic sign of pericarditis so it is expected, but should be documented in the patient’s record.

NCLEX-RN® REVIEW Test Question 7 An appropriate goal of nursing care for the patient with acute infective endocarditis would be which of the following? “Will resume usual activities within 1 week of treatment.” “Will relate the benign and self-limiting nature of the disease.” “Will consider cardiac transplantation as a viable treatment option.” “Will state the importance of continuing intravenous antibiotic therapy as ordered.”

NCLEX-RN® REVIEW Test Question 7 Response An appropriate goal of nursing care for the patient with acute infective endocarditis would be which of the following? “Will resume usual activities within 1 week of treatment.” “Will relate the benign and self-limiting nature of the disease.” “Will consider cardiac transplantation as a viable treatment option.” “Will state the importance of continuing intravenous antibiotic therapy as ordered.”

NCLEX-RN® REVIEW Test Question 7 Rationale Effective treatment for acute infective endocarditis requires long-term intravenous antibiotic therapy to eliminate the infecting organisms.

NCLEX-RN® REVIEW Test Question 8 An expected assessment finding in a patient with mitral stenosis being admitted for a valve replacement would be which of the following? muffled heart sounds S3 and S4 heart sounds diastolic murmur heard at the apex cardiac heave

NCLEX-RN® REVIEW Test Question 8 Response An expected assessment finding in a patient with mitral stenosis being admitted for a valve replacement would be which of the following? muffled heart sounds S3 and S4 heart sounds diastolic murmur heard at the apex cardiac heave

NCLEX-RN® REVIEW Test Question 8 Rationale The murmur of mitral valve stenosis would be heard during diastole (when blood is flowing through the stenotic valve from the atrium to the ventricle) at the apex of the heart.

NCLEX-RN® REVIEW Test Question 9 A patient facing heart valve replacement asks the nurse which type of valve is the best, biologic or mechanical. An appropriate response would be which of the following?

NCLEX-RN® REVIEW Test Question 9 Choices The need to take drugs to prevent rejection of biologic tissue is a major consideration. Clotting is a risk with mechanical valves, necessitating anticoagulant drug therapy after insertion. Biologic valves tend to be more durable than mechanical valves. Endocarditis is a risk following valve replacement; it is more easily treated with mechanical valves. 32

NCLEX-RN® REVIEW Test Question 9 Response The need to take drugs to prevent rejection of biologic tissue is a major consideration. Clotting is a risk with mechanical valves, necessitating anticoagulant drug therapy after insertion. Biologic valves tend to be more durable than mechanical valves. Endocarditis is a risk following valve replacement; it is more easily treated with mechanical valves.

NCLEX-RN® REVIEW Test Question 9 Rationale Anticoagulant therapy to prevent clot formation is necessary following insertion of a mechanical valve.

NCLEX-RN® REVIEW Test Question 10 The parents of a young athlete who collapsed and died due to hypertrophic cardiomyopathy ask the nurse how it is possible that their son had no symptoms of this disorder before experiencing sudden cardiac death. The nurse responds with which of the following?

NCLEX-RN® REVIEW Test Question 10 Choices “Exercise causes the heart to contract more forcefully, and can lead to changes in the heart’s rhythm or the outflow of blood from the heart in people with hypertrophic cardiomyopathy.” “It is likely that your son had symptoms of the disorder before he died, but he may not have thought them important enough to tell someone about.” 36

NCLEX-RN® REVIEW Test Question 10 Choices “In this type of cardiomyopathy, the ventricle does not fill normally. During exercise, the heart may not be able to meet the body’s needs for blood and oxygen.” “Cardiomyopathy results in destruction and scarring of cardiac muscle cells. As a result, the ventricle may rupture during strenuous exercise, leading to sudden death.” 37

NCLEX-RN® REVIEW Test Question 10 Response “Exercise causes the heart to contract more forcefully, and can lead to changes in the heart’s rhythm or the outflow of blood from the heart in people with hypertrophic cardiomyopathy.” “It is likely that your son had symptoms of the disorder before he died, but he may not have thought them important enough to tell someone about.” 38

NCLEX-RN® REVIEW Test Question 10 Response “In this type of cardiomyopathy, the ventricle does not fill normally. During exercise, the heart may not be able to meet the body’s needs for blood and oxygen.” “Cardiomyopathy results in destruction and scarring of cardiac muscle cells. As a result, the ventricle may rupture during strenuous exercise, leading to sudden death.” 39

NCLEX-RN® REVIEW Test Question 10 Rationale In hypertrophic cardiomyopathy, manifestations may not develop until the demand for oxygen increases, such as with athletes during activity, causing sudden death due to a ventricular dysrhythmia. This type of cardiomyopathy is not a filling problem but rather an obstruction to ejection of blood to the body to meet oxygen demand.

Lecture Note Presentation

Learning Outcome 1 Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

Heart Failure Etiology Pathophysiology Manifestations

Heart Failure Systolic and diastolic failure Left-sided and right-sided heart failure

Figure 31–1 The hemodynamic effects of left-sided heart failure.

Figure 31–2 The hemodynamic effects of right-sided heart failure.

Heart Failure Low- versus high-output failure Acute versus chronic heart failure Pulmonary Edema Etiology, pathophysiology, and manifestations Rheumatic fever/rheumatic heart disease

Heart Failure Infective and inflammatory diseases of the heart Etiology, pathophysiology, manifestations: Infective endocarditis Myocarditis Pericarditis

Figure 31–9 Constrictive pericarditis Figure 31–9 Constrictive pericarditis. Source: Custom Medical Stock Photo, Inc.

Valvular Heart Disease Etiology Pathophysiology Manifestations

Figure 31–10 Valvular heart disorders. A, Stenosis of a heart valve Figure 31–10 Valvular heart disorders. A, Stenosis of a heart valve. B, An incompetent or regurgitant heart valve.

Figure 31–11 Mitral stenosis Figure 31–11 Mitral stenosis. Narrowing of the mitral valve orifice (1) reduces blood volume to left ventricle (2), which reduces cardiac output (3). Rising pressure in the left atrium (4) causes left atrial hypertrophy and pulmonary congestion. Increased pressure in pulmonary vessels (5), causes hypertrophy of the right ventricle and right atrium. 52

Figure 31–12 Mitral regurgitation Figure 31–12 Mitral regurgitation. The mitral valve closes incompletely (1), allowing blood to regurgitate during systole from the left ventricle to the left atrium (2). Cardiac output falls; to compensate, the left ventricle hypertrophies (3). Rising left atrial pressure (4) causes left atrial hypertrophy and pulmonary congestion. Elevated pulmonary artery pressure (5) causes slight enlargement of the right ventricle. 53

Figure 31–13 Mitral valve prolapse Figure 31–13 Mitral valve prolapse. Excess tissue in the valve leaflets (1) and elongated cordae tendineae (2) impair mitral valve closure during systole. Some ventricular blood regurgitates into the left atrium (3). 54

Figure 31–14 Aortic stenosis Figure 31–14 Aortic stenosis. The narrowed aortic valve orifice (1) decreases the left ventricular ejection fraction during systole (2) and cardiac output (3). The left ventricle hypertrophies (4). Incomplete emptying of the left atrium (5) causes backward pressure through pulmonary veins and pulmonary hypertension. Elevated pulmonary artery pressure (6) causes right ventricular strain. 55

Figure 31–15 Aortic regurgitation Figure 31–15 Aortic regurgitation. The cusps of the aortic valve widen and fail to close during diastole (1). Blood regurgitates from the aorta into the left ventricle (2) increasing left ventricular volume and decreasing cardiac output (3). The left ventricle dilates and hypertrophies (4) in response to the increase in blood volume and workload. 56

Valvular Heart Disease Tricuspid stenosis Tricuspid regurgitation Pulmonic stenosis Pulmonic regurgitation

Cardiomyopathy Etiology, pathophysiology, and manifestations Primary and secondary Dilated Hypertrophic Restrictive

Learning Outcome 2 Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

Heart failure: Risk factors Coronary artery disease Cardiomyopathies Hypertension

Congenital and Valvular Heart Disease Prevention Education: reduce risks Coronary artery disease and DM

Rheumatic Fever and Rheumatic Heart Disease Risk factors Crowded living conditions Malnutrition Immunodeficiency Poor access to health care Genetic factors Prevention Prompt identification, treatment Compliance: medications

Infective Endocarditis Risk factors Congenital deformities Tissue damage due to ischemic disease Valve prosthesis Intravenous drug use Invasive catheters Dental health Recent heart surgery

Infective Endocarditis Prevention Education Prophylactic antibiotics

Myocarditis Risk factors: Alteration of immune response Advanced age Malnutrition Alcohol use Immunosuppression Exposure to radiation Stress

Valvular Heart Disease Prevention of rheumatic fever Early and effective treatment of strep throat Completing the full prescription of antibiotic Prophylactic antibiotic therapy

Learning Outcome 3 Discuss indications for and management of patients undergoing hemodynamic monitoring.

Hemodynamics Study of forces involved in blood circulation Main goals Evaluation of cardiac and circulatory function Evaluation of responses to interventions

Hemodynamics Hemodynamic parameters Heart rate Arterial blood pressure Central venous or right atrial pressure Pulmonary pressure Cardiac output

Hemodynamics Measurement Nursing Care Focus Directly Indirectly Safety Infection control Accuracy of measurement Knowledge of equipment being used

Learning Outcome 4 Discuss the effects and nursing implications for medications commonly prescribed for patients with cardiac disorders.

Heart Failure Medications used to treat heart failure ACE inhibitors Angiotensin II receptor blockers Beta blockers Diuretics Inotropic medications Direct vasodilators Antidysrhythmic drug

Heart Failure Nursing diagnoses Decreased Cardiac Output Excess Fluid Volume Activity Intolerance Deficient Knowledge: Low-Sodium Diet

Pulmonary Edema Medications to treat pulmonary edema: Morphine sulfate Potent loop diuretics such as furosemide Vasodilators such as nitroprusside; dopamine or dobutamine Aminophylline to reduce bronchospasm

Pulmonary Edema Nursing diagnoses: Impaired Gas Exchange Decreased Cardiac Output Fear

Rheumatic Fever Medications used to treat rheumatic fever: Antibiotics Penicillin Erythromycin, Clindamycin Anti-inflammatory drugs Nursing diagnoses Acute Pain Activity Intolerance

Infective Endocarditis Medications used to treat infective endocarditis: Prolonged course of antibiotics Nursing Diagnoses Risk for Imbalanced Body Temperature Risk for Ineffective Tissue Perfusion Ineffective Health Maintenance

Myocarditis Medications used to treat myocarditis: Antibiotics and antiviral therapy, if infection Immunosuppressives to minimize the inflammatory response ACE inhibitors and other drugs Digitalis used with caution Antidysrhythmic agents Anticoagulants

Myocarditis Nursing diagnoses Activity Intolerance Decreased Cardiac Output Fatigue Anxiety Excess Fluid Volume

Pericarditis Medications used to treat pericarditis: Determined by manifestations ASA and acetaminophen NSAIDs Corticosteroids Pericardiocentesis

Pericarditis Nursing Diagnoses Acute Pain Ineffective Breathing Pattern Risk for Decreased Cardiac Output Activity Intolerance

Valvular Heart Disease Medications used to treat valvular heart disease: Diuretics, ACE inhibitors, vasodilators, digitalis if heart failure Digitalis, small doses of beta blockers, anticoagulant therapy if atrial fibrillation Prophylactic antibiotics prior to any dental work or surgery

Valvular Heart Disease Surgery and invasive procedures Percutaneous balloon valvuloplasty Valvuloplasty Open commissurotomy Annuloplasty Valve replacement Nursing diagnoses Decreased Cardiac Output

Valvular Heart Disease Activity Intolerance Risk for Infection Ineffective Protection

Cardiomyopathies Medications used to treat cardiomyopathies Dilated and restrictive cardiomyopathies ACE inhibitors, vasodilators, and digitalis Beta blockers with caution in dilated cardiomyopathy Anticoagulants and antidysrhythmics

Cardiomyopathies Medications used to treat cardiomyopathies Hypertrophic cardiomyopathy Beta blockers Vasodilators, digitalis, nitrates, and diuretics are contraindicated

Cardiomyopathies Surgery and invasive treatments Cardiac transplant Ventricular assist devices Removal of excess muscle Dual-chamber pacemakers Implantable cardioverter-defibrillators

Cardiomyopathies Nursing diagnoses Decreased Cardiac Output Fatigue Ineffective Breathing Pattern Fear Ineffective Role Performance Anticipatory Grieving

Learning Outcome 5 Describe nursing care for the patient undergoing cardiac surgery or cardiac transplant.

Placement of a Circulatory Assistance Device Intra-aortic balloon pump Left-ventricular assist device

Nursing Care of the Heart Transplant Patient Similar to care of any cardiac surgery patient Monitor chest tube drainage Monitor cardiac rate and rhythm Monitor cardiac output, pulmonary artery pressures, and CVP

Nursing Care Rewarming procedures Administration of IV medications

Aggressive Nursing Care to Prevent Infection Limit visitors with communicable diseases Pulmonary hygiene Early ambulation Strict aseptic technique