Question

A nurse reviews the echocardiogram results of a patient admitted with crackles and shortness of breath. The report shows a left ventricular ejection fraction (EF) of 35%. What is the most appropriate nursing action based on this EF result?

Answer 1

Correct Answers:

Notify the healthcare provider immediately to discuss possible adjustments in treatment for systolic heart failure.

Rationale :

❤️ An ejection fraction (EF) of 35% indicates systolic heart failure, meaning the left ventricle cannot pump blood effectively.

❤️ This reduced EF explains the client’s crackles and shortness of breath, which result from pulmonary congestion and fluid overload.

❤️ Prompt provider notification allows for medication optimization, such as adjusting diuretics, ACE inhibitors, beta-blockers, or other heart-failure therapies.

❤️ Early intervention helps prevent worsening respiratory distress and cardiac decompensation.

❤️ Nursing recognition and escalation are essential to improve outcomes and reduce hospitalization complications.

❌ Incorrect Options

❌ Administer a diuretic immediately to raise the ejection fraction to normal levels.

Diuretics relieve fluid overload but do not directly normalize EF. Medication changes must be prescribed by the provider.

❌ Document the EF as normal and continue routine monitoring during the next scheduled assessment.

An EF of 35% is abnormal and requires prompt action. Routine monitoring alone delays necessary treatment.

❌ Encourage the patient to increase physical activity to improve heart function without consulting the provider.

Unsupervised activity can worsen symptoms in systolic heart failure. Activity plans must be provider-directed.

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Answer 2

Correct Answers:

Monitor daily weights and intake and output to assess fluid status.
Place the client in high-Fowler's position to improve lung expansion and oxygenation.
Encourage fluid and sodium restriction as prescribed.

Rationale :

✅ Monitor daily weights and intake and output

🫁 Daily weight monitoring is the most sensitive indicator of fluid retention in clients with worsening heart failure.

🫁 Strict intake and output measurement allows the nurse to evaluate fluid balance and the effectiveness of diuretic therapy.

🫁 Even small increases in weight can signal early fluid overload before respiratory symptoms worsen.

🫁 This intervention helps detect trends that may indicate decompensation or treatment failure.

🫁 Consistent monitoring supports timely clinical decisions and helps prevent pulmonary edema and hospitalization.

✅ Place the client in high-Fowler's position

🫁 High-Fowler’s position decreases venous return to the heart, reducing pulmonary congestion.

🫁 Upright positioning allows maximum lung expansion, improving ventilation and oxygenation.

🫁 This position helps relieve dyspnea and orthopnea, which are common in heart failure exacerbations.

🫁 It reduces the work of breathing by improving diaphragmatic movement.

🫁 Positioning is an immediate, noninvasive intervention that enhances respiratory comfort and gas exchange.

✅ Encourage fluid and sodium restriction

🫁 Excess sodium and fluid intake worsen fluid retention, increasing cardiac workload.

🫁 Restriction helps control edema and pulmonary congestion, key features of worsening heart failure.

🫁 Sodium limitation enhances the effectiveness of diuretics and other heart failure medications.

🫁 Fluid control reduces the risk of acute exacerbations and respiratory distress.

🫁 Adherence to prescribed restrictions is essential for long-term symptom management and stability.

❌ Incorrect Options

❌ Apply warm compresses to extremities to improve circulation

Warm compresses do not address the underlying problem of fluid overload or impaired cardiac pumping. This intervention has no therapeutic benefit in worsening heart failure.

❌ Encourage the client to increase physical activity immediately to prevent deconditioning

Immediate activity can worsen dyspnea, fatigue, and oxygen demand in an unstable client. Physical activity should be gradual and provider-directed once the client is stabilized.

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Answer 3

Correct Answers:

"You will notice a small hematoma at the incision site."

Rationale :

🩹 A small hematoma or mild bruising at the catheter insertion site is a common and expected finding after cardiac catheterization.

🩹 This occurs due to vessel puncture and localized bleeding during sheath removal.

🩹 Clients should be taught to monitor the site for changes such as increasing size, firmness, warmth, or active bleeding.

🩹 Early education helps reduce anxiety and promotes prompt reporting of complications.

🩹 Understanding expected post-procedure findings supports safe recovery and effective self-care at home.

❌ Incorrect Options

❌ “The dressing should be changed within 12 hours of the procedure.”

The dressing is typically kept intact for at least 24 hours unless otherwise instructed. Early removal increases the risk of bleeding.

❌ “Pain medication will not be necessary.”

Mild discomfort is common after catheterization. Prescribed or over-the-counter analgesics may be needed for comfort.

❌ “You can resume regular exercise as soon as tomorrow.”

Strenuous activity should be avoided for several days to prevent bleeding or hematoma expansion at the access site.

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Answer 4

Correct Answers:

Muffled heart sounds.

Rationale :

🫀 Cardiac tamponade occurs when blood accumulates rapidly in the pericardial sac, compressing the heart and impairing ventricular filling.

🫀 The presence of muffled or distant heart sounds results from fluid dampening the transmission of cardiac sounds through the chest wall.

🫀 This finding is a classic component of Beck’s triad, which is strongly associated with acute cardiac tamponade.

🫀 As compression increases, cardiac output decreases, leading to hemodynamic instability.

🫀 Early recognition of muffled heart sounds is critical because cardiac tamponade is a life-threatening emergency requiring immediate intervention.

❌ Incorrect Options

❌ Sudden lethargy.

Lethargy is a nonspecific finding that can occur with many conditions, including hypoxia or shock. It does not specifically indicate cardiac tamponade.

❌ Bradycardia.

Clients with cardiac tamponade typically develop tachycardia as a compensatory response to decreased cardiac output. Bradycardia is not an expected early finding.

❌ Flattened neck veins.

Cardiac tamponade causes jugular venous distention, not flattened veins, due to impaired venous return to the heart.

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Answer 5

Correct Answers:

Limit sodium intake to 2 to 3 grams per day.

Rationale :

🫀 Sodium plays a key role in fluid balance, and excess sodium intake causes the body to retain water, worsening fluid overload in heart failure.

🫀 Limiting sodium to 2–3 grams per day helps reduce edema, pulmonary congestion, and shortness of breath.

🫀 Sodium restriction decreases the workload on the heart by lowering circulating fluid volume.

🫀 This dietary control also enhances the effectiveness of diuretics, which are commonly prescribed in heart failure.

🫀 Prioritizing sodium restriction is one of the most effective non-pharmacologic strategies to prevent heart failure exacerbations.

❌ Incorrect Options

❌ Consume packaged soups and canned vegetables regularly.

Packaged and canned foods are typically high in sodium. Regular consumption increases the risk of fluid retention and worsening heart failure symptoms.

❌ Increase daily fluid intake to more than 3 liters.

Excess fluid intake can overwhelm a weakened heart and worsen pulmonary and peripheral edema. Fluid intake is usually restricted, not increased.

❌ Avoid monitoring daily weight to reduce anxiety.

Daily weights are a critical early indicator of fluid retention. Avoiding weight monitoring delays detection of worsening heart failure.

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Answer 6

Rationale :

⚡ The T-wave represents ventricular repolarization, which occurs after the ventricles contract.

⚡ On an ECG, it appears as a smooth, rounded wave following the QRS complex.

⚡ In hyperkalemia, the T-wave becomes tall, peaked, and narrow, making it more prominent than normal.

⚡ These changes occur because elevated potassium alters cardiac cell membrane excitability and repolarization timing.

⚡ Recognizing T-wave abnormalities is critical, as severe hyperkalemia can progress to life-threatening dysrhythmias.

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Answer 7

Correct Answers:

Heart rate

Rationale :

❤️ Cardiac output (CO) is calculated using the formula: CO = Stroke Volume (SV) × Heart Rate (HR).

❤️ Therefore, obtaining the heart rate is essential because it is one of the two required components in the calculation.

❤️ Heart rate represents the number of times the heart pumps per minute, directly influencing overall blood flow to tissues.

❤️ Without heart rate data, the nurse cannot accurately determine the amount of blood the heart pumps each minute.

❤️ Understanding this formula is fundamental in assessing cardiac function and perfusion status in clinical practice.

❌ Incorrect Options

❌ Respiratory rate

Respiratory rate reflects ventilation, not cardiac pumping ability. It is not used in calculating cardiac output.

❌ Temperature

Temperature can influence heart rate but is not part of the cardiac output formula. It does not directly calculate blood flow.

❌ Blood pressure

Blood pressure reflects vascular resistance and cardiac function but is not directly multiplied to determine cardiac output.

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Answer 8

Rationale :

🦵 After a left femoral cardiac angiography, the nurse must assess distal circulation to ensure there is no arterial obstruction or impaired blood flow.

🦵 The most distal pulse in the lower extremity is the dorsalis pedis pulse, located on the top of the foot.

🦵 In the image, Area 3 corresponds to the pulse location on the left foot, which is distal to the femoral access site.

🦵 Monitoring this pulse helps detect complications such as arterial occlusion, thrombosis, or decreased perfusion.

🦵 Early identification of diminished or absent distal pulses is critical to prevent limb ischemia and permanent tissue damage.

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Answer 9

Correct Answers:

Assess pulses in the client's affected arm.

Rationale :

🫀 After a left-sided cardiac catheterization via an upper extremity insertion site (such as radial or brachial access), the priority is to monitor for vascular compromise.

🫀 Assessing distal pulses in the affected arm helps determine if adequate blood flow is maintained beyond the insertion site.

🫀 Complications such as arterial occlusion, hematoma formation, or thrombus development can impair circulation.

🫀 Early detection of diminished pulses, pallor, coolness, or numbness allows for rapid intervention to prevent ischemic injury.

🫀 Neurovascular assessment is a critical safety measure following upper-extremity catheterization.

❌ Incorrect Options

❌ Encourage the client to ambulate within 30 min following the procedure.

Early ambulation depends on the access site and provider protocol. Activity is typically limited initially to prevent bleeding.

❌ Apply light pressure to the insertion site.

Pressure is applied immediately after sheath removal to achieve hemostasis, not routinely afterward unless bleeding occurs.

❌ Keep the client NPO for at least 2 hr following the procedure.

Clients are usually allowed to resume oral intake once stable unless sedation or complications require otherwise.

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Answer 10

Correct Answers:

Perform neurovascular checks with vital signs.

Rationale :

🩺 After a cardiac catheterization via the femoral artery, the client is at risk for bleeding, hematoma formation, and arterial occlusion.

🩺 Performing neurovascular checks includes assessing distal pulses, skin temperature, color, capillary refill, sensation, and movement in the affected extremity.

🩺 These assessments help detect early signs of impaired circulation or limb ischemia, which are serious complications.

🩺 Vital signs must be monitored alongside neurovascular status to identify hypotension or tachycardia related to internal bleeding.

🩺 Early recognition of complications ensures prompt intervention and prevents permanent tissue damage or hemodynamic instability.

❌ Incorrect Options

❌ Ambulate the client 1 hr following the procedure.

Clients with femoral access are typically required to remain on bed rest for several hours to prevent bleeding. Early ambulation increases the risk of hemorrhage at the insertion site.

❌ Instruct the client to perform range-of-motion exercises to his lower extremities.

Movement of the affected leg can disrupt the clot at the insertion site and cause bleeding. The extremity should remain straight and immobilized initially.

❌ Restrict the client's fluid intake.

Fluids are usually encouraged to help flush out contrast dye and prevent renal complications. Restricting fluids is not routine unless otherwise indicated.

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☑️Custom 2601 NUR 213 Exam 2 Cardiac One

No.

1 :
A nurse reviews the echocardiogram results of a patient admitted with crackles and shortness of breath. The report shows a left ventricular ejection fraction (EF) of 35%. What is the most appropriate nursing action based on this EF result?

2 :
A nurse is caring for a client admitted with worsening heart failure. Which of the following nursing interventions should the nurse implement? (Select all that apply)

3 :
A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?

4 :
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

5 :
A nurse is teaching a client with newly diagnosed heart failure about dietary management to control fluid retention. Which instruction should the nurse prioritize to reduce the risk of fluid overload?

7 :
A nurse is planning to calculate a client's cardiac output. Which of the following data should the nurse obtain to calculate the cardiac output?

9 :
A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site. Which of the following actions should the nurse take?

10 :
A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

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☑️Custom 2601 NUR 213 Exam 2 Cardiac One

No.

1 : A nurse reviews the echocardiogram results of a patient admitted with crackles and shortness of breath. The report shows a left ventricular ejection fraction (EF) of 35%. What is the most appropriate nursing action based on this EF result?

2 : A nurse is caring for a client admitted with worsening heart failure. Which of the following nursing interventions should the nurse implement? (Select all that apply)

3 : A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?

4 : A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

5 : A nurse is teaching a client with newly diagnosed heart failure about dietary management to control fluid retention. Which instruction should the nurse prioritize to reduce the risk of fluid overload?

7 : A nurse is planning to calculate a client's cardiac output. Which of the following data should the nurse obtain to calculate the cardiac output?

9 : A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site. Which of the following actions should the nurse take?

10 : A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

1 :
A nurse reviews the echocardiogram results of a patient admitted with crackles and shortness of breath. The report shows a left ventricular ejection fraction (EF) of 35%. What is the most appropriate nursing action based on this EF result?

2 :
A nurse is caring for a client admitted with worsening heart failure. Which of the following nursing interventions should the nurse implement? (Select all that apply)

3 :
A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?

4 :
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

5 :
A nurse is teaching a client with newly diagnosed heart failure about dietary management to control fluid retention. Which instruction should the nurse prioritize to reduce the risk of fluid overload?

7 :
A nurse is planning to calculate a client's cardiac output. Which of the following data should the nurse obtain to calculate the cardiac output?

9 :
A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site. Which of the following actions should the nurse take?

10 :
A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?