Chapter 25- Prep U

The nurse is teaching a client with heart failure about digoxin. What statements by the client indicate the teaching is effective? Select all that apply. A. "The medication will increase my heart rate and my blood pressure." B. "If I take my digoxin I should have limited episodes of shortness of breath." C. "Digoxin therapy requires monthly drug levels." D. "The digoxin will increase my appetite, so I should weight myself daily." E. "I will watch my urine output to be sure that the medication is not affecting my kidneys."

A. "The medication will increase my heart rate and my blood pressure." B. "If I take my digoxin I should have limited episodes of shortness of breath." Rationale: Digoxin is excreted by the kidneys and causes renal failure, so the client should monitor urine output. Digoxin therapy will increase ventricular output, so it can be effective in decreasing heart failure symptoms like shortness of breath. Digoxin toxicity may can anorexia, not increased appetite. Digoxin therapy will slow AV conduction, not increase heart rate or blood pressure. A client taking digoxin therapy will have levels drawn if symptoms of toxicity or renal function changes are present.

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea? A. Call for a chest x-ray. B. Listen for breath sounds over the epigastrium. C. Observe for mist in the endotracheal tube. D. Attach a pulse oximeter probe and obtain values.

A. Call for a chest x-ray. Rationale: A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.

Which medication reverses digitalis toxicity? A. Digoxin immune FAB B. Amlodipine C. Ibuprofen D. Warfarin

A. Digoxin immune FAB Rationale: Digoxin immune FAB binds with digoxin and makes it unavailable for use. The dosage is based on the digoxin concentration and the client's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.

The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide? A. Potassium level of 3.1 B. Sodium level of 135 C. BNP of 100 D. Hemoglobin of 12

A. Potassium level of 3.1 Rationale: Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These drugs increase sodium and therefore water excretion, but they also increase potassium excretion. If a client becomes hypokalemic, digitalis toxicity is more likely. The BNP does not demonstrate a severe heart failure. Sodium level of 135 is within normal range, as is the hemoglobin level.

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)? A. Spironolactone B. Bumetanide C. Ethacrynic acid D. Chlorothiazide

A. Spironolactone Rationale: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide diuretic is Diuril. Bumetanide and ethacrynic acid are loop diuretics.

Which is a potassium-sparing diuretic used in the treatment of heart failure? A. Spironolactone B. Chlorothiazide C. Ethacrynic acid D. Bumetanide

A. Spironolactone Rationale: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide diuretic. Bumetanide and ethacrynic acid are loop diuretics.

Which is a manifestation of right-sided heart failure? A. Systemic venous congestion B. Accumulation of blood in the lungs C. Increase in forward flow D. Paroxysmal nocturnal dyspnea

A. Systemic venous congestion Rationale: Right-sided heart failure causes systemic venous congestion and a reduction in forward flow. Left-sided heart failure causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues. Some clients with left-sided heart failure get episodes of dyspnea at night, known as paroxysmal nocturnal dyspnea.

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival? A. lisinopril B. cholestyramine C. diltiazem D. bumetanide

A. lisinopril Rationale: Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, beta-blockers, and diuretics such as bumetanide. Many of these medications, particularly ACE inhibitors and beta-blockers, improve symptoms and extend survival. Others, such as diuretics, improve symptoms but may not affect survival. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.

The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart? A. MRI B. echocardiogram C. pulmonary arterial pressure D. nuclear angiography

B. echocardiogram Rationale: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. An MRI, pulmonary arterial pressure, and nuclear angiography do not give diagnostic information about the heart's ejection fraction.

The nurse instructs a client with heart failure on restricting sodium in the diet. Which client statement indicates that teaching was effective? A. "I will add a water softener to my water at home." B. "Lemon juice and herbs can be used to replace salt when cooking." C. "Food prepared at home is saltless unless I add it while cooking." D. "Canned vegetables have low sodium content."

B. "Lemon juice and herbs can be used to replace salt when cooking." Rationale: For the client on a low-sodium or sodium-restricted diet, a variety of flavorings, such as lemon juice, vinegar, and herbs, may be used to improve the taste of the food and facilitate acceptance of the diet. Sodium is contained in municipal water. Water softeners also increase the sodium content of drinking water. Although the major source of sodium in the average American diet is salt, many types of natural foods contain varying amounts of sodium. Even if no salt is added in cooking and if salty foods are avoided, the daily diet will still contain about 2000 mg of sodium. Fresh fruits and vegetables are low in sodium and should be encouraged.

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? A. Blood urea nitrogen (BUN) B. Brain natriuretic peptide (BNP) C. Complete blood count (CBC) D. Creatinine

B. Brain natriuretic peptide (BNP) Rationale: BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.

The nursing instructor is teaching their clinical group how to assess a client for congestive heart failure. How would the instructor teach the students to assess a client with congestive heart failure for nocturnal dyspnea? A. By measuring the client's abdominal girth B. By questioning how many pillows the client normally uses for sleep C. By observing the client's diet during the day D. By collecting the client's urine output

B. By questioning how many pillows the client normally uses for sleep Rationale: The nurse should ask the client about nocturnal dyspnea by questioning how many pillows the client normally uses for sleep. This is because being awakened by breathlessness may prompt the client to use several pillows in bed. Collecting the client's urine output, observing the client's diet, or measuring the client's abdominal girth does not help assess for nocturnal dyspnea.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? A. Blood urea nitrogen (BUN) B. Echocardiogram C. Electrocardiogram (ECG) D. Serum electrolytes

B. Echocardiogram Rationale: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.

The nurse is preparing to administer hydralazine and isosorbide dinitrate. When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse? A. Administer a saline bolus of 250 mL and then administer the medication. B. Hold the medication and call the health care provider. C. Administer the medication and check the blood pressure in 30 minutes. D. Administer the hydralazine and hold the dinitrate.

B. Hold the medication and call the health care provider. Rationale: A combination of hydralazine and isosorbide dinitrate may be another alternative for patients who cannot take ACE inhibitors (ICSI, 2011). Nitrates (e.g., isosorbide dinitrate) cause venous dilation, which reduces the amount of blood return to the heart and lowers preload. Hydralazine lowers systemic vascular resistance and left ventricular afterload. If these medications lead to severe hypotension, the nurse should hold the medication and call the health care provider.

A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client? A. Oxygen cannula at 6 L/minute B. Intubation and mechanical ventilation C. Face mask with nonrebreather D. Venturi mask at 35%

B. Intubation and mechanical ventilation Rationale: The client's respiratory status is severely compromised and has developed signs of respiratory failure. When respiratory failure occurs, the client is intubated and oxygen is administered under continuous positive airway pressure or with mechanical ventilation with positive end-expiratory pressure. A face mask, cannula, or Venturi mask will not deliver the concentration or ventilatory support that an endotracheal tube with mechanical ventilation will provide.

Which feature is the hallmark of systolic heart failure? A. Basilar crackles B. Low ejection fraction (EF) C. Pulmonary congestion D. Limited activities of daily living (ADLs)

B. Low ejection fraction (EF) Rationale: A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.

Which describes difficulty breathing when a client is lying flat? A. Bradypnea B. Orthopnea C. Tachypnea D. Paroxysmal nocturnal dyspnea (PND)

B. Orthopnea Rationale: Orthopnea occurs when the client is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.

The client with cardiac failure is taught to report which symptom to the health care provider or clinic immediately? A. Weight loss B. Persistent cough C. Increased appetite D. Ability to sleep through the night

B. Persistent cough Rationale: Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite, weight gain, interrupted sleep, unusual shortness of breath, and increased swelling should also be reported immediately.

A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals coarse crackles in the lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing A. bilateral pneumonia. B. decompensated heart failure with pulmonary edema. C. tuberculosis. D. acute exacerbation of chronic obstructive pulmonary disease.

B. decompensated heart failure with pulmonary edema. Rationale: The production of large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), indicates acute decompensated heart failure with pulmonary edema. These signs can be confused with those of pneumonia and tuberculosis. However, auscultation reveals coarse crackles, which indicate pulmonary edema. A patient with acute COPD would have diminished lung sounds bilaterally.

The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion? A. nocturia B. inadequate cardiac output C. hepatomegaly D. ascites

B. inadequate cardiac output Rationale: Pulmonary congestion occurs and tissue perfusion is compromised and diminished when the heart, primarily the left ventricle, cannot pump blood out of the ventricle effectively into the aorta and the systemic circulation. Ascites is fluid in the abdomen, not a cause of congestion. Hepatomegaly is an enlarged liver, which does not cause crackling breath sounds. Nocturia, or voiding at night, does not cause crackling breath sounds.

A nurse suspects that a client has digoxin toxicity. The nurse should assess for: A. decreased urine output. B. vision changes. C. gait instability. D. hearing loss.

B. vision changes. Rationale: Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.

When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating A. dyspnea upon exertion. B. hyperpnea. C. orthopnea. D. paroxysmal nocturnal dyspnea.

C. orthopnea. Rationale: Clients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler position. Dyspnea upon exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

A client is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client? A. Warfarin B. Amlodipine C. Digoxin immune FAB D. Ibuprofen

C. Digoxin immune FAB Rationale: Digibind binds with digoxin and makes it unavailable for use. The digibind dosage is based on the digoxin level and the patient's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? A. Calcium B. Platelet count C. Potassium D. White blood cell (WBC) count

C. Potassium Rationale: Diuretics, such as furosemide (Lasix), are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin (Lanoxin), and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? A. The development of right-sided heart failure B. The development of cor pulmonale C. The development of left-sided heart failure D. The development of chronic obstructive pulmonary disease (COPD)

C. The development of left-sided heart failure Rationale: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.

The client asks the nurse why a stress test is needed. What statement best explains the rationale for the health care provider to order a cardiac stress test? A. The stress test is the best diagnostic tool to monitor which stage of heart failure the client is experiencing. B. Heart failure is causing the client to be weak and tired. C. The health care provider wants to identify if the heart failure is from coronary artery disease. D. The health care provider needs to evaluate everything.

C. The health care provider wants to identify if the heart failure is from coronary artery disease. Rationale: Cardiac stress testing or cardiac catheterization is performed to determine whether the coronary artery disease and cardiac ischemia are causing the heart failure. The nurse is generalizing when saying everything is being evaluated. Explaining that heart failure is causing weakness and fatigue does not answer the need for the stress test. The stress test does not diagnose the client's stage of heart failure.

A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals coarse crackles in the lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing A. tuberculosis. B. acute exacerbation of chronic obstructive pulmonary disease. C. decompensated heart failure with pulmonary edema. D. bilateral pneumonia.

C. decompensated heart failure with pulmonary edema. Rationale: The production of large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), indicates acute decompensated heart failure with pulmonary edema. These signs can be confused with those of pneumonia and tuberculosis. However, auscultation reveals coarse crackles, which indicate pulmonary edema. A patient with acute COPD would have diminished lung sounds bilaterally.

A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment? A. increased cardiac output B. drowsiness, numbness C. moist, gurgling respirations D. hypertension

C. moist, gurgling respirations Rationale: Clients with acute pulmonary edema experience sudden dyspnea, wheezing, orthopnea, cough, cyanosis, and tachycardia. Respirations sound moist or gurgling. Drowsiness and numbness are not considered issues. Increased cardiac output is not part of this checklist. Hypertension is not an immediate symptom.

The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity? A. calcium level of 7.5 mg/dL B. sodium level of 152 mEq/L C. potassium level of 2.8 mEq/L D. magnesium level of 2.5 mg/dL

C. potassium level of 2.8 mEq/L Rationale: Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.

The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information? A. "Are you coughing up blood at night?" B. "How far can you walk without becoming short of breath?" C. "Are you urinating excessively at night?" D. "Are you only able to breathe when you are sitting upright?"

D. "Are you only able to breathe when you are sitting upright?" Rationale: To determine if a client is having orthopnea, the nurse needs to ask about the inability to breathe unless sitting upright. Determining how far the client can walk without becoming short of breath would indicate exertional dyspnea. Coughing up blood would indicate hemoptysis. Urinating excessively at night can be indicative of different factors such as taking a diuretic late in the evening causing the client to urinate often at night. This question would be vague.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? A. "My feet are bigger than normal." B. "I don't have the same appetite I used to." C. "My pants don't fit around my waist." D. "I sleep on three pillows each night."

D. "I sleep on three pillows each night." Rationale: Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing action? A. Administer diuretics B. Administer angiotensin-converting enzyme inhibitors C. Administer angiotensin II receptor blockers D. Assess oxygen saturation

D. Assess oxygen saturation Rationale: The nurse's priority action is to assess oxygen saturation to determine the severity of the exacerbation. It is important to assess the oxygen saturation in a client with heart failure because below-normal oxygen saturation can be life-threatening. Treatment options vary according to the severity of the client's condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve symptoms and reduce the workload on the heart by reducing afterload and preload.

Which is a key diagnostic indicator of heart failure? A. Creatinine B. Complete blood count (CBC) C. Blood urea nitrogen (BUN) D. Brain natriuretic peptide (BNP)

D. Brain natriuretic peptide (BNP) Rationale: BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. BUN, creatinine, and a CBC are included in the initial workup.

A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload? A. Supine with arms elevated on pillows above the level of the heart B. Head of the bed elevated 30 degrees and legs elevated on pillows C. Prone with legs elevated on pillows D. Head of the bed elevated 45 degrees and lower arms supported by pillows

D. Head of the bed elevated 45 degrees and lower arms supported by pillows Rationale: Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the client's weight on the shoulder muscles.

The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client? A. Low-fat diet B. Low-potassium diet C. Low-cholesterol diet D. Low-sodium diet

D. Low-sodium diet Rationale: Medical management of both left-sided and right-sided heart failure is directed at reducing the heart's workload and improving cardiac output primarily through dietary modifications, drug therapy, and lifestyle changes. A low-sodium diet is prescribed, and fluids may be restricted. Because the client will be on a diuretic such as Lasix, he may become potassium depleted and would need potassium in the diet. A low-cholesterol and low-fat diet may be ordered but are not specific to the heart failure.

The nurse recognizes which symptom as a classic sign of cardiogenic shock? A. Hyperactive bowel sounds B. Increased urinary output C. High blood pressure D. Restlessness and confusion

D. Restlessness and confusion Rationale: Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).

A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure? A. Left-sided heart failure B. Chronic heart failure C. Acute heart failure D. Right-sided heart failure

D. Right-sided heart failure Rationale: Signs and symptoms of Right Ventricular Failure include: Weakness; Ascites; Weight gain; Nausea, vomiting; Dysrhythmias; Elevated central venous pressure; Jugular vein distention. The scenario does not indicate whether the heart failure is chronic or acute. Therefore, options A, B, and C are incorrect.

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound? A. a fourth heart sound (S4). B. a first heart sound (S1). C. a murmur. D. a third heart sound (S3).

D. a third heart sound (S3). Rationale: An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.

A client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition? A. pneumonia. B. cardiogenic shock. C. right-sided heart failure. D. acute pulmonary edema.

D. acute pulmonary edema. Rationale: Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured? A. cardiac catheterization B. cardiac ultrasound C. electrocardiogram D. echocardiogram

D. echocardiogram Rationale: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan, not an electrocardiogram or cardiac ultrasound. Cardiac catheterization is not the diagnostic tool for this measurement.

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client? A. Flexion contractures B. Enlargement of joints C. Vasculitis D. nausea and vomiting

D. nausea and vomiting Rationale: Digitalis medications are potent and may cause various toxic effects. The nurse should monitor the client for signs of digitalis toxicity, not just during the initial period of therapy, but throughout care management. The most common signs and symptoms include nausea and vomiting which can lead to dehydration and electrolyte imbalance. Symptoms of toxicity do not include vasculitis, flexion contractures, or enlargement of joints.