Which disorder would the nurse recognize as the likely cause of right heart failure (cor pulmonale)?

Upper GI bleeding

Chronic obstructive pulmonary disease (COPD)

Liver failure

Renal failure

Answer and Explanation

The Correct Answer is B

Choice A reason: Upper GI bleeding is not a direct cause of right heart failure (cor pulmonale). While severe GI bleeding can lead to other complications such as anemia or shock, it does not typically result in cor pulmonale.

Choice B reason: Chronic obstructive pulmonary disease (COPD) is a primary cause of cor pulmonale. COPD leads to chronic hypoxia, which increases pressure in the pulmonary arteries (pulmonary hypertension). The right ventricle of the heart must work harder to pump blood through these high-pressure arteries, eventually leading to right heart failure.

Choice C reason: Liver failure can lead to various systemic complications such as fluid imbalance and electrolyte disturbances, but it is not a direct cause of right heart failure (cor pulmonale). Cor pulmonale is specifically related to pulmonary conditions that increase right ventricular workload.

Choice D reason: Renal failure, while serious and capable of causing cardiovascular complications due to fluid overload and hypertension, is not typically linked to the development of cor pulmonale. The primary cause of cor pulmonale is chronic lung disease like COPD, which directly affects the pulmonary vasculature.

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Correct Answer is A

Explanation

Choice A reason: Contacting the health care provider is the most appropriate action because a change in the Doppler sound may indicate a potential complication, such as graft occlusion or compromised blood flow. Immediate assessment and intervention by the health care provider are essential to prevent further complications and ensure the patient's safety.

Choice B reason: Rechecking the pulse in another 30 minutes is not advisable in this situation because it could delay necessary medical intervention. Prompt communication with the health care provider is crucial to address the underlying issue and provide timely care.

Choice C reason: Measuring the ankle-brachial index can provide valuable information about blood flow in the lower extremities, but it is not the immediate priority when a significant change in the Doppler sound is detected. Contacting the health care provider for further assessment and instructions takes precedence.

Choice D reason: Administering an oral anticoagulant is not an appropriate action without the direct instruction from a health care provider. The nurse must first report the change in the Doppler sound to the provider and follow their specific orders regarding medication and treatment.

A. Oxygen mask B. Nasogastric tube C. Urinary catheter D. Suction set-up E. Tongue blade F. Side rail pads

Correct Answer is ["A","D","F"]

Explanation

Choice A reason: An oxygen mask is essential for providing supplemental oxygen to the patient, especially if they experience respiratory distress or decreased oxygen saturation following a seizure. Ensuring adequate oxygenation is a priority in post-seizure care.

Choice B reason: A nasogastric tube may be used in specific situations for feeding or medication administration, but it is not routinely necessary for all patients treated for status epilepticus.

Choice C reason: A urinary catheter is used for managing urinary output, particularly in patients with retention or incontinence issues, but it is not immediately required for all patients post-status epilepticus.

Choice D reason: Suction set-up is necessary for maintaining the patient's airway and preventing aspiration, particularly if the patient has excessive secretions or vomits after a seizure. Suction equipment allows the nurse to quickly clear the airway and ensure the patient can breathe effectively.

Choice E reason: Tongue blades are not recommended for seizure management as they can cause injury. Historically, there was a misconception about using tongue blades to prevent tongue biting during seizures, but this practice is now discouraged due to the risk of oral injury.

Choice F reason: Side rail pads are important for protecting the patient from injury during potential future seizures. Padded side rails help prevent trauma from hitting the bed rails during convulsions and provide a safer environment for the patient.

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Which disorder would the nurse recognize as the likely cause of right heart failure (cor pulmonale)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides postoperative care to a patient who underwent peripheral artery bypass surgery. Thirty minutes after the initial assessment, the nurse reassesses the patient and detects a change in the Doppler sound over a pulse. Which action should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is ["A","D","F"]

Explanation

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