Proctored Cardiac and Respiratory (Martin SP25)

Correct Answer: A. Control fluid balance

Explanation:

Heart failure exacerbations in older adults are most commonly triggered by fluid overload, leading to symptoms such as shortness of breath, swelling in the legs, and weight gain. Controlling fluid balance is the primary goal to prevent hospital readmissions. This includes adhering to prescribed diuretics, monitoring daily weight, restricting sodium intake, and educating patients on early warning signs of fluid retention. Proper fluid management reduces congestion in the lungs and prevents worsening heart failure symptoms, which significantly decreases the frequency of hospitalizations.

Why the Other Options Are Incorrect:

B. Control blood pressure

While managing hypertension is important in preventing heart failure progression, it is not the most immediate concern in reducing hospitalizations due to acute exacerbations. Many patients with heart failure already experience low or fluctuating blood pressure, making fluid balance a higher priority in acute management. Blood pressure control is a long-term strategy for heart failure management, but it does not directly prevent acute decompensations that lead to hospitalization.

C. Prevent deconditioning

Deconditioning, or muscle weakening due to inactivity, is a concern in chronic heart failure management, but it is not the primary cause of hospital admissions. Encouraging activity is important for overall well-being, but patients experiencing acute heart failure symptoms often need to prioritize fluid balance before engaging in physical activity. Fluid overload causes breathlessness and fatigue, making exercise difficult; thus, addressing fluid retention first is essential before focusing on physical activity.

D. Maintain patient safety

Ensuring patient safety is always a priority, but it does not directly reduce hospitalizations for heart failure exacerbations. Safety concerns, such as fall prevention and medication adherence, are important in general care but do not target the primary issue causing acute exacerbations, which is fluid overload. Managing fluid balance has a more direct impact on hospital admission rates than general safety measures.

Summary:

The most important goal in reducing hospitalizations for heart failure exacerbations in older adults is controlling fluid balance. Fluid retention leads to worsening symptoms, pulmonary congestion, and hospital admissions. Managing fluid balance through diuretics, sodium restriction, daily weight monitoring, and patient education is the most effective strategy to prevent acute decompensations. While blood pressure control, physical activity, and patient safety are important, they do not directly address the main cause of frequent hospitalizations, which is fluid overload. Therefore, controlling fluid balance is the most critical nursing intervention for reducing hospital readmissions in older adults with heart failure.

Three Findings That Require Immediate Follow-Up

A. Decreased lung sounds

B. Heart rate of 110 per minute

D. Subcutaneous emphysema

Explanation

A thoracentesis is a procedure in which fluid is removed from the pleural space to improve breathing and diagnose underlying conditions. While it is generally safe, complications such as pneumothorax, bleeding, or infection can occur. The nurse must closely monitor for any signs of distress or worsening respiratory function.

A. Decreased Lung Sounds - Requires Immediate Follow-Up

Diminished or absent lung sounds after thoracentesis can indicate pneumothorax, re-accumulation of fluid, or lung collapse. Since this patient has a history of frequent pleural effusions and lung cancer, the risk of complications is higher. The nurse should assess the patient further and notify the provider immediately.

D. Subcutaneous Emphysema - Requires Immediate Follow-Up

Subcutaneous emphysema is the presence of air trapped under the skin, often caused by air leaking from the lungs into the surrounding tissues. This can indicate a lung injury or pneumothorax following the thoracentesis. The nurse should monitor for increasing swelling or crepitus and ensure the patient is not developing respiratory distress.

B. Heart Rate of 110 per Minute - Requires Immediate Follow-Up

An elevated heart rate (tachycardia) can be an early sign of hypoxia, respiratory distress, or even tension pneumothorax. Since the patient had a thoracentesis, tachycardia may indicate worsening respiratory function, fluid imbalance, or stress on the cardiovascular system. Immediate assessment is needed to rule out serious complications.

Why the Other Options Do Not Require Immediate Follow-Up

C. Oxygen Saturation of 95 Percent - Does Not Require Immediate Follow-Up

An oxygen saturation of 95 percent is within normal limits and suggests that the patient is maintaining adequate oxygenation. No immediate intervention is required at this time.

E. Trachea Midline - Does Not Require Immediate Follow-Up

A midline trachea is a reassuring sign, as tracheal deviation can indicate a tension pneumothorax or severe respiratory distress. Since the trachea is in the expected position, there is no urgent concern related to this finding.

F. Puncture Site Dry - Does Not Require Immediate Follow-Up

A dry puncture site indicates that there is no active bleeding or drainage from the thoracentesis site. While the site should continue to be monitored for signs of infection, it does not require immediate follow-up.

Summary

The three findings that require immediate follow-up are decreased lung sounds, subcutaneous emphysema, and a heart rate of 110 per minute. These findings may indicate complications such as pneumothorax, lung injury, or respiratory distress. The nurse should assess the patient further, monitor for worsening symptoms, and notify the provider as needed.

Correct Answer: B. Sinoatrial (SA) node

Rationale:

The sinoatrial (SA) node is known as the natural pacemaker of the heart because it initiates the electrical impulse that regulates the heart's rhythm. It is located in the right atrium and generates impulses at a normal resting rate of 60 to 100 beats per minute.

Why the Other Options Are Incorrect:

A. Atrioventricular (AV) node

The AV node is located between the atria and ventricles. It functions as a secondary pacemaker, but it does not initiate the heart's impulse under normal conditions. It delays the impulse before transmitting it to the ventricles, allowing the atria to contract before the ventricles. If the SA node fails, the AV node can take over at a rate of 40 to 60 beats per minute.

C. Bundle of His

The Bundle of His is located in the interventricular septum and conducts impulses from the AV node to the right and left bundle branches. It helps transmit impulses to the ventricles, but it does not initiate the heartbeat.

D. Purkinje fibers

The Purkinje fibers are located in the ventricular walls and are responsible for the final distribution of the electrical impulse, triggering ventricular contraction. They generate impulses at a much slower rate (about 20 to 40 beats per minute) if both the SA and AV nodes fail.

Key Takeaways About the Heart’s Electrical Conduction System:

SA node (pacemaker): Starts the impulse (60–100 bpm).

AV node: Delays impulse, can act as a backup pacemaker (40–60 bpm).

Bundle of His: Conducts impulses to ventricles.

Purkinje fibers: Distribute impulses to ventricular muscle (20–40 bpm if no higher pacemaker is active). Thus, the SA node is responsible for initiating the heart’s electrical impulse

Correct Answer:C. Ascites

Rationale:

Right-sided heart failure occurs when the right ventricle fails to pump blood effectively, leading to systemic venous congestion. This results in fluid accumulation in the body, including the abdomen (ascites), lower extremities (dependent edema), and jugular veins (jugular venous distension).

Why the Other Options Are Incorrect:

A. Pulmonary emboli

Pulmonary emboli are not a symptom of right-sided heart failure, though they can cause right-sided heart failure due to increased pulmonary pressure

B. Hypertension

Hypertension is a risk factor for heart failure but is more commonly associated with left-sided heart failure due to increased afterload.

D. Orthopnea

Orthopnea, or difficulty breathing while lying flat, is a classic symptom of left-sided heart failure, not right-sided. Left-sided heart failure leads to pulmonary congestion, causing shortness of breath.

Key Symptoms of Right-Sided Heart Failure:

Peripheral edema (swelling in legs, ankles, feet)

Jugular venous distension (JVD)

Hepatomegaly and splenomegaly (enlarged liver and spleen)

Ascites (fluid accumulation in the abdomen)

Weight gain due to fluid retention

Nocturia (frequent urination at night due to fluid redistribution)

​​​​​​​Thus, ascites is a common symptom of right-sided heart failure due to systemic venous congestion.

Correct Answer: C. Avoid sick people and wash hands

Explanation:

The most important patient teaching for preventing hospitalizations due to COPD exacerbations is infection prevention, which includes avoiding sick people and practicing good hand hygiene. Respiratory infections, particularly viral and bacterial infections, are the leading cause of COPD exacerbations, often leading to increased inflammation, mucus production, and airway obstruction. Hospitalizations for COPD exacerbations are most commonly triggered by respiratory infections such as the flu, pneumonia, or bronchitis. Encouraging patients to get vaccinated against influenza and pneumonia, maintain proper handwashing habits, and avoid crowded areas or sick individuals significantly reduces their risk of acquiring infections. Early recognition of symptoms, such as increased cough, shortness of breath, or sputum production, is also critical in preventing complications.

Why the Other Options Are Incorrect:

A. Ease breathing by sitting upright

Sitting upright can help ease breathing by improving lung expansion, but it does not directly prevent COPD exacerbations or hospitalizations. While positioning is useful for symptom management, it does not address the root cause of most exacerbations, which is infection or exposure to environmental triggers.

B. Use low-flow oxygen for dyspnea

Oxygen therapy is important for COPD patients with chronic hypoxemia, but it is not the primary measure for preventing hospitalizations. Not all COPD patients require oxygen therapy, and improper use can lead to CO₂ retention, which can worsen respiratory distress. While oxygen helps manage symptoms, it does not prevent the occurrence of exacerbations, which are mainly caused by infections and environmental factors.

D. Eat nutrient- and calorie-dense foods

Proper nutrition is essential for maintaining energy levels and preventing muscle wasting, but it does not directly prevent COPD exacerbations. Malnutrition can worsen COPD outcomes, but infection control remains the most critical factor in reducing hospitalizations. Encouraging a balanced diet supports overall health but does not replace the need for infection prevention strategies.

Summary:

The most important strategy to prevent COPD exacerbations and hospitalizations is infection prevention. Avoiding sick people, practicing good hand hygiene, and receiving vaccinations significantly reduce the risk of respiratory infections, which are the leading cause of COPD exacerbations. While upright positioning, oxygen therapy, and proper nutrition are all beneficial for managing COPD, they do not directly prevent hospitalizations caused by acute exacerbations. Therefore, the priority teaching for discharge is infection prevention through avoiding exposure to sick individuals and frequent handwashing.

Correct Answer: C. Vital capacity

Rationale:

Vital capacity (VC) is the maximum amount of air that can be expelled from the lungs after a maximal inhalation. It represents the total amount of air that a person can voluntarily move in and out of their lungs.

Vital Capacity (VC)=Tidal Volume (TV)+Inspiratory Reserve Volume (IRV)+Expiratory Reserve Volume (ERV)\

Measured by: Pulmonary function tests (PFTs)

Clinical significance: Reduced in restrictive lung diseases (e.g., pulmonary fibrosis)

Why the Other Options Are Incorrect:

A. Tidal Volume (TV)

The amount of air inhaled or exhaled during normal breathing (~500 mL in adults). It does not measure maximal air movement like vital capacity does.

B. Inspiratory Reserve Volume (IRV)

The extra amount of air that can be inhaled after a normal inspiration. It is a component of vital capacity but does not measure total exhalation ability.

D. Residual Volume (RV)

The amount of air left in the lungs after maximal exhalation (prevents lung collapse). It cannot be voluntarily exhaled and is not part of vital capacity.

Key Takeaway:

Vital Capacity (VC) = Maximum air expelled after maximal inhalation

Formula: VC = TV + IRV + ERV

Used to assess: Lung function in pulmonary diseases

The correct answers are: 

Pharmacist

Pulmonologist

Respiratory Therapist

Cardiologist.

Explanation

Pharmacist – A pharmacist plays a crucial role in managing medications for a client with respiratory failure. This includes ensuring the correct dosage and administration of medications such as bronchodilators, corticosteroids, or antibiotics, as well as monitoring for drug interactions and side effects.

Pulmonologist – A pulmonologist specializes in diseases and conditions affecting the lungs and respiratory system. Since respiratory failure directly impacts lung function, a pulmonologist is essential in diagnosing and managing the underlying causes, prescribing treatments, and determining the need for mechanical ventilation or other interventions.

Respiratory Therapist – A respiratory therapist provides hands-on care and therapeutic interventions for patients with breathing difficulties. This includes administering oxygen therapy, managing ventilators, performing pulmonary function tests, and assisting with airway clearance techniques to improve the patient's respiratory status.

Cardiologist – A cardiologist may be involved in the care of a patient with respiratory failure because heart conditions such as congestive heart failure or pulmonary hypertension can contribute to respiratory distress. The cardiologist helps assess and manage any underlying cardiovascular issues that might be exacerbating the patient's condition.

Explanation of Incorrect Answer

Neurologist – A neurologist specializes in disorders of the nervous system, including the brain and spinal cord. While neurological conditions such as stroke or neuromuscular disorders (e.g., ALS, myasthenia gravis) can lead to respiratory failure, a neurologist is not routinely involved in the immediate management of respiratory failure unless the failure is directly linked to a neurological disorder. Therefore, a neurologist is not necessarily a primary team member in this case.

Summary

The healthcare team for a client with respiratory failure typically includes a pharmacist to manage medications, a pulmonologist for specialized lung care, a respiratory therapist for direct breathing support and ventilator management, and a cardiologist if heart-related issues are contributing to the condition. A neurologist is generally not involved unless the respiratory failure has a neurological cause.

Correct Answer: D. Pulmonary angiography

Rationale:

Pulmonary angiography is the gold standard and most definitive diagnostic test for pulmonary embolism (PE) because it provides a direct visualization of blood flow in the pulmonary arteries. It involves injecting a contrast dye into the pulmonary vasculature and using imaging (typically CT or fluoroscopy) to detect any obstructions.

Why the Other Options Are Incorrect:

A. Chest X-ray

Not a definitive test for PE. May help rule out other conditions like pneumonia or pneumothorax but often appears normal in PE. Sometimes shows nonspecific findings like atelectasis or pleural effusion.

B. Arterial Blood Gas (ABG) Analysis

Can indicate hypoxemia (low oxygen levels) and respiratory alkalosis (from hyperventilation), but not specific for PE. Used as a supportive test, not for definitive diagnosis.

C. D-dimer Test

A screening test that measures fibrin degradation products (indicating clot breakdown). High sensitivity but low specificity—many conditions (infection, pregnancy, trauma) can cause elevated D-dimer. A normal D-dimer can help rule out PE, but a positive result does not confirm it.

Key Takeaway:

Pulmonary angiography is the most definitive test for pulmonary embolism, as it provides direct imaging of a clot blocking pulmonary circulation. However, in clinical practice, a CT pulmonary angiography (CTPA) is commonly used due to its non-invasive nature and high accuracy.

Correct Answer: D. ST-segment elevation

Rationale:

ST-segment elevation on an electrocardiogram (ECG) is the most indicative finding of an acute myocardial infarction (MI), specifically a ST-elevation myocardial infarction (STEMI). It occurs due to complete occlusion of a coronary artery, leading to myocardial ischemia and injury.

Other ECG Changes Associated with MI:

Inverted T waves: Indicate ischemia but are not as specific for an acute MI as ST elevation.

Pathologic Q waves: Suggest previous or evolving infarction.

Why the Other Options Are Incorrect:

A. Prolonged PR interval

Indicates first-degree heart block, which affects AV node conduction but is not indicative of an MI.

B. Peaked P waves

Suggest right atrial enlargement (e.g., pulmonary hypertension, chronic lung disease) but are not associated with MI.

C. Inverted T waves

Indicate ischemia but are not the most definitive sign of an MI. T-wave inversions may also be seen in other conditions like pericarditis or electrolyte imbalances.

Key Takeaway:

ST-segment elevation is the most significant ECG indicator of an acute myocardial infarction (STEMI) and requires immediate intervention to restore coronary blood flow (e.g., PCI or thrombolytics)