Congestive Heart Failure Practice Questions (Test #5, Fall 2020)

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

1 1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation. 2. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation. 3. A pulse oximeter reading of greater than 93% is considered normal. 4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure. TEST-TAKING HINT: Because the nurse will be assessing each client, the test taker must determine which client is a priority. A general guideline for this type of question is for the test taker to ask "Is this within normal limits?" or "Is this expected for the disease process?" If the answer is yes to either question, then the test taker can eliminate these options and look for abnormal data that would make that client a priority.

The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan.

1 1. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF. 2. An elevated CK-MB would indicate a myocardial infarction, not severe CHF. CK-MB is an isoenzyme. 3. A positive D-dimer would indicate a pulmonary embolus. 4. A positive ventilation/perfusion (V/Q) scan (ratio) would indicate a pulmonary embolus. TEST-TAKING HINT: This question requires the test taker to discriminate among CHF, MI, and PE. If unsure of the answer of this type of question, the test taker should eliminate any answer options that the test taker knows are wrong. For example, the test taker may not know about pulmonary embolus but might know that CK-MB data are used to monitor MI and be able to eliminate option "2" as a possibility. Then, there is a 1:3 chance of getting the correct answer

Which medication should the nurse question administering to a client diagnosed with stage C CHF? 1. Ibuprofen. 2. Amlodipine. 3. Spironolactone. 4. Atenolol.

1 1. Ibuprofen (Motrin) is an NSAID. NSAIDs promote sodium retention and peripheral vasoconstriction—interventions that can make CHF worse. Additionally, they reduce the effi cacy and intensify the toxicity of diuretics and ACE inhibitors. The nurse should question this medication 2. Amlodipine (Norvasc) is a CCB. As a category of medications, CCBs are contraindicated in a client diagnosed with CHF; however, the CCB Norvasc is an exception: it alone among the CCBs has been shown not to reduce life expectancy. Norvasc may be given to the client safely. 3. Spironolactone (Aldactone), a potassium-sparing diuretic, is prescribed for clients in stage C CHF in addition to loop diuretics for its diuretic effect without causing potassium loss. 4. Atenolol (Tenormin) is a beta blocker. Beta blockers have been shown to improve life expectancy, although clinical symptoms may not improve. The nurse would not question administering this medication.

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and CRT less than three (3) seconds.

1 1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status. 2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing. 3. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored breathing, not eupnea, which means normal breathing. 4. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status. TEST-TAKING HINT: In option "3," the word "no" is an absolute term and, usually, absolutes, such as "no," "never," "always," and "only," are incorrect because there is no room for any other possible answer. If the test taker is looking for abnormal data, then the test taker should exclude the options that have normal values in them, such as eupnea, pulse rate of 90, and capillary refill time (CRT) less than three (3) seconds.

The nurse is transcribing the doctor's orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement? 1. Discuss the order with the health-care provider. 2. Take the client's apical pulse rate before administering. 3. Check the client's potassium level before giving the medication. 4. Determine if a digoxin level has been drawn.

1 1. This dosage is 10 times the normal dose for a client with CHF. This dose is potentially lethal. 2. No other action can be taken because of the incorrect dose. 3. No other action can be taken because of the incorrect dose. 4. No other action can be taken because of the incorrect dose.

Which data would cause the nurse to question administering digoxin to a client diagnosed with congestive heart failure? 1. The potassium level is 3.2 mEq/L. 2. The digoxin level is 1.2 mcg/mL. 3. The client's apical pulse is 64. 4. The client denies yellow haze

1 1. This potassium level is below normal levels; hypokalemia can potentiate digoxin toxicity and lead to cardiac dysrhythmias. 2. This digoxin level is within therapeutic range, 0.5 to 2 mcg/mL. 3. The nurse would question the medication if the apical pulse were less than 60. 4. Yellow haze is a sign of digoxin toxicity

Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? 1.5 to 10 minutes. 2.30 to 60 minutes. 3.2 to 4 hours. 4.6 to 8 hours

1 After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.

The major goal of nursing care for a client with heart failure and pulmonary edema is to: 1.Increase cardiac output. 2.Improve respiratory status. 3.Decrease peripheral edema. 4.Enhance comfort.

1 Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission which of the following should the nurse assess first? 1.Blood pressure. 2.Skin breakdown. 3.Serum potassium level. 4.Urine output.

1 It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and when the nurse obtains a complete health history, the nurse should inspect the client's skin for any signs of breakdown; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? 1.Assess respiratory status. 2.Draw blood for laboratory studies. 3.Insert a Foley catheter. 4.Weigh the client.

1 The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.

The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which of the following are expected findings on assessment? Select all that apply. 1.Decreased cardiac output. 2.Increased heart rate. 3.Vasoconstriction in skin, GI tract, and kidneys. 4.Decreased pulmonary perfusion. 5.Fluid overload.

1, 2, 3, 5. Heart failure can be a result of several cardiovascular conditions, which will affect the heart's ability to pump effectively. The body attempts to compensate through several neurohormonal mechanisms. Decreased cardiac output stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the heart rate and contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process resulting in the release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure, therefore cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary disease.

When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply. 1.Becoming increasingly short of breath at rest. 2.Weight gain of 2 lb (0.9 kg) or more in 1 day. 3.High intake of sodium for breakfast. 4.Having to sleep sitting up in a reclining chair. 5.Weight loss of 2 lb (0.9 kg) in 1 day.

1, 2, 4. If the client will call the physician when there is increasing shortness of breath, weight gain over 2 lb (0.9 kg) in 1 day, and need to sleep sitting up, this indicates an understanding of the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the physician if he or she had consumed a high-sodium breakfast. Instead the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future.

The home health nurse is caring for a client diagnosed with congestive heart failure (CHF) who has been prescribed digoxin and furosemide. Which statements by the client indicate the medications are effective? Select all that apply. 1. "I am able to walk next door now without being short of breath." 2. "I keep my feet propped up as much as I can during the day." 3. "I have not gained any weight since my last doctor's visit." 4. "My blood pressure has been within normal limits." 5. "I am staying on my diet, and I don't salt my foods anymore."

1,3, 1. Digoxin (Lanoxin), a cardiac glycoside, and furosemide (Lasix), a loop diuretic, are administered for clients diagnosed with CHF to improve the contractility of the cardiac muscle and to decrease the fluid volume overload. A symptom of CHF is shortness of breath. The fact that the client can ambulate without being short of breath is an improvement of symptoms, which shows that the medications are effective. 2. This statement indicates compliance with treatment guidelines, not effectiveness of a medication. 3. Weight gain would indicate that the client is retaining fluid and the medications are not effective. No weight gain indicates the medication is effective. 4. A client with CHF does not have HTN; therefore, a normal blood pressure does not indicate the medications are effective. 5. This statement indicates compliance with treatment guidelines, not effectiveness of a medication. MEDICATION MEMORY JOGGER: The nurse determines the effectiveness of a medication by assessing for the symptoms, or lack thereof, for which the medication was prescribed.

The nurse should assess the client with left-sided heart failure for which of the following? Select all that apply. 1.Dyspnea. 2.Jugular vein distention (JVD). 3.Crackles. 4.Right upper quadrant pain. 5.Oliguria. 6.Decreased oxygen saturation levels.

1,3,5,6 Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure

The client diagnosed with CHF is prescribed enalapril. Which statement explains the scientific rationale for administering this medication? 1. Enalapril increases the levels of angiotensin II in the blood vessels. 2. Enalapril dilates arteries, which reduces the workload of the heart. 3. Enalapril decreases the effects of bradykinin in the body. 4. Enalapril blocks the intervention of antidiuretic hormone in the kidney

2 1. ACE inhibitors decrease the level of angiotensin in the body by blocking the conversion from angiotensin I to angiotensin II. 2. Enalapril (Vasotec) is an ACE inhibitor. By reducing the levels of angiotensin II, ACE inhibitors dilate blood vessels, reduce blood volume, and prevent or reverse angiotensin II pathological changes in the heart and kidneys. 3. ACE inhibitors increase bradykinin levels. 4. ACE inhibitors have no effect on the intervention of the antidiuretic hormone

The HCP prescribed an angiotensin-converting enzyme (ACE) inhibitor for a client diagnosed with CHF. Which instruction should the nurse provide? 1. "Eat a banana or drink orange juice at least twice a day." 2. "Notify the HCP if you develop localized edematous areas that itch." 3. "Expect to have a dry cough early in the morning on arising." 4. "Your symptoms of congestive heart failure should improve rapidly."

2 1. ACE inhibitors have a side effect of hyperkalemia. The client should not be encouraged to eat potassium-rich foods. 2. A condition in which there are localized edematous areas (wheals), accompanied by intense itching of the skin and mucous membranes, is called angioedema. This is an adverse reaction to an ACE inhibitor and should be reported to the HCP. 3. An intractable dry cough is a reason for discontinuing the ACE inhibitor and should be reported to the HCP. 4. Symptomatic improvement may take weeks to months to develop for a client diagnosed with CHF.

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? 1. The client will be able to ambulate in the hall by date of discharge. 2. The client will have an audible S1 and S2 with no S3 heard by end of shift. 3. The client will turn, cough, and deep breathe every two (2) hours. 4. The client will have a SaO2 reading of 98% by day two (2) of care

2 1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis. 2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure, which could be life threatening. 3. This is a nursing intervention, not a short-term goal, for this client. 4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output. TEST-TAKING HINT: When reading a nursing diagnosis or problem, the test taker must be sure that the answer selected addresses the problem. An answer option may be appropriate care for the disease process but may not fit with the problem or etiology. Remember, when given an etiology in a nursing diagnosis, the answer will be doing something about the problem (etiology). In this question the test taker should look for an answer that addresses the ability of the heart to pump blood.

What is the priority problem in the client diagnosed with congestive heart failure? 1. Fluid volume overload. 2. Decreased cardiac output. 3. Activity intolerance. 4. Knowledge deficit

2 1. Fluid volume overload is a problem in clients with congestive heart failure, but it is not priority because, if the cardiac output is improved, then the kidneys are perfused, which leads to elimination of excess fluid from the body. 2. Decreased cardiac output is responsible for all the signs/symptoms associated with CHF and eventually causes death, which is why it is the priority problem. 3. Activity intolerance alters quality of life, but it is not life threatening. 4. Knowledge deficit is important, but it is not priority over a physiological problem.

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking the medication with food.

2 1. If a cough develops, the client should notify the health-care provider because this is an adverse reaction and the HCP will discontinue the medication. 2. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored. 3. ACE inhibitors may cause the client to retain potassium; therefore, the client should not increase potassium intake. 4. An ACE inhibitor should be taken one (1) hour before meals or two (2) hours after a meal to increase absorption of the medication. TEST-TAKING HINT: If the test taker knows that an ACE inhibitor is also given for hypertension, then looking at answer options referring to hypotension would be appropriate.

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

2 1. The client with peripheral edema will experience calf tightness but would not have leg cramping, which is the result of low potassium levels. The timing of the diuretic will not change the side effect of leg cramping resulting from low potassium levels. 2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium. 3. Weight gain is monitored in clients with CHF, and elevating the legs would decrease peripheral edema by increasing the rate of return to the central circulation, but these interventions would not help with leg cramps. 4. Ambulating frequently and performing legstretching exercises will not be effective in alleviating the leg cramps. TEST-TAKING HINT: The timing "at night" in this question was not important in answering the question, but it could have made the test taker jump at option "1." Be sure to read all answer options before deciding on an answer. Answering this question correctly requires knowledge of the side effects of treatments used for CHF

When assessing an older adult, the nurse finds the apical impulse below the fifth intercostal space. The nurse should further assess the client for: 1.Left atrial enlargement. 2.Left ventricular enlargement. 3.Right atrial enlargement. 4.Right ventricular enlargement

2 A normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.

Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet? 1.Apples. 2.Tomato juice. 3.Whole wheat bread. 4.Beef tenderloin.

2 Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice

A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing which of the following? 1.Dilated coronary arteries. 2.Increased myocardial contractility. 3.Decreased cardiac arrhythmias. 4.Decreased electrical conductivity in the heart.

2 Digoxin is a cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat arrhythmias and does decrease the electrical conductivity of the myocardium, these are not primary reasons for its use in clients with heart failure and pulmonary edema.

A client has a history of heart failure and has been furosemide (Lasix), digoxin (Lanoxin), and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which of the following? 1.Hyperkalemia. 2.Digoxin toxicity. 3.Fluid deficit. 4.Pulmonary edema.

2 Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.

A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply. 1.Angel food cake. 2.Banana. 3.Dried fruit. 4.Orange juice. 5.Peppers.

2, 3, 4 Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake, yellow cake, and peppers are low in potassium.

The nurse is administering digoxin to a client diagnosed with CHF. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's carotid pulse for 1 full minute. 2. Check the client's current potassium level. 3. Ask the client if he or she is seeing a yellow haze around objects. 4. Have the client squeeze the nurse's fingers. 5. Teach the client to get up slowly from a sitting position

2,3 1. The client's apical pulse, not the carotid pulse, should be assessed. 2. Digoxin (Lanoxin) is a cardiac glycoside used to treat heart failure. The client's potassium level, as well as the digoxin level, is monitored because high levels of potassium impair therapeutic response to digoxin and low levels can cause toxicity. The most common cause of dysrhythmias in clients receiving digoxin is hypokalemia from diuretics that are usually given simultaneously. 3. Yellow haze indicates the client may have high serum digoxin levels. The therapeutic range for digoxin is relatively small (0.5 to 1.2), and levels of 2.0 or greater are considered toxic. 4. This is part of a neurological assessment and not needed for digoxin. 5. This would be an intervention to prevent orthostatic hypotension. Digoxin does not affect blood pressure.

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify the health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct the client to remove the saltshaker from the dinner table. 4. Encourage the client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2,3 1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day. 2. The client should not take digoxin if the radial pulse is less than 60. 3. The client should be on a low-sodium diet to prevent water retention. 4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase with diuretics. 5. Instruct the client to take the diuretic in the morning to prevent nocturia. TEST-TAKING HINT: This is an alternative-type question—in this case, "Select all that apply." If the test taker missed this statement, it is possible to jump at the first correct answer. This is one reason that it is imperative to read all options before deciding on the correct one(s). This could be a clue to reread the question for clarity. Another hint that this is an alternative question is the number of options. The other questions have four potential answers; this one has five. Numbers in an answer option are always important. Is one (1) pound enough to indicate a problem that should be brought to the attention of the health-care provider?

The client diagnosed with stage D CHF has a brain natriuretic peptide (BNP) level greater than 1,500. Which medication should the nurse anticipate the HCP prescribing? 1. Captopril orally. 2. Digoxin IVP. 3. Dobutamine IV. 4. Metoprolol orally

3 1. Captopril (Capoten) is an ACE inhibitor. ACE inhibitors should be prescribed for clients with diabetes, hyperlipidemia, and HTN when in stage A heart failure. 2. Digoxin (Lanoxin), a cardiac glycoside, is prescribed in stage C heart failure. 3. Dobutamine (Dobutrex), a synthetic catecholamine, is given for short-term IV therapy for clients in stage D CHF and is preferred to dopamine because it does not increase vascular resistance. Dobutamine increases myocardial contractility and cardiac output. 4. Metoprolol (Lopressor) is a beta blocker. Beta blockers are prescribed in stage C heart failure. The client may not see an improvement of symptoms, but research has demonstrated that beta blockers can prolong life even in the absence of clinical improvement

The nurse in the HCP's office is completing an assessment on a client who has been prescribed digoxin for CHF. Which data indicates the medication has been effective? 1. The client's sputum is pink and frothy. 2. The client has 2+ pitting edema of the sacrum. 3. The client has clear breath sounds bilaterally. 4. The client's heart rate is 78 bpm

3 1. Pink, frothy sputum indicates that the client's lungs are filling with fluid. This indicates the client's condition is becoming worse. 2. Pitting edema of the sacrum would be seen in clients on bedrest. This is a symptom of CHF and would only indicate the client is getting better if the client had 3+ or 4+ edema initially. 3. Digoxin (Lanoxin) is a cardiac glycoside. Clear lung sounds bilaterally indicate the treatment is effective. The nurse assesses for the signs and symptoms of the disease for which the medication is being administered. If the symptoms are resolving, then the medication is effective. 4. The client's heart rate must be 60 bpm or above to administer digoxin safely, but the heart rate does not indicate the client with CHF is getting better.

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention.

3 1. Pitting edema changing from 3+ to 4+ indicates a worsening of the CHF. 2. The client's ability to take the radial pulse would evaluate teaching, not medical treatment. 3. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs. 4. Any jugular vein distention indicates that the right side of the heart is failing, which would not indicate effective medical treatment. TEST-TAKING HINT: When asked to determine whether treatment is effective, the test taker must know the signs and symptoms of the disease being treated. An improvement in the signs and symptoms indicates effective treatment.

The nurse is providing discharge instructions for a client prescribed hydrochlorothiazide. Which instruction(s) should the nurse include? 1. Drink at least 8 to 10 glasses of water a day. 2. Weigh yourself monthly and report the weight to the HCP. 3. Eat bananas or oranges regularly. 4. Try to sleep in an upright position

3 1. The client should drink enough fluid to replace insensible losses (e.g., through perspiration and in feces) or the client will become dehydrated; however, the client should not drink 8 to 10 glasses of water per day. The medication is being given to reduce the amount of fluid in the body. 2. The client should weigh himself or herself daily in the same amount of clothes and at approximately the same time for accuracy in weight measurement. The client should report a weight gain of 3 pounds within a week. 3. Hydrochlorothiazide (Diuril) is a thiazide diuretic. Loop and thiazide diuretics cause the body to excrete potassium in the urine. The client should attempt to replace the potassium by eating potassium-rich foods such as bananas and orange juice. 4. The client does not need to sleep in an upright position if the CHF is being controlled. If the client has to sleep in an upright position to breathe, the HCP should be notified.

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain on inspiration and a nonproductive cough

3 1. This client is stable because discharge is scheduled for the following day. Therefore, this client does not need to be assigned to the most experienced registered nurse. 2. This client is more in need of custodial nursing care than care from the most experienced registered nurse. Therefore, the charge nurse could assign a less experienced nurse to this client. 3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client. 4. These complaints usually indicate muscular or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration. This client does not require the care of an experienced nurse as much as does the client with signs of shock. TEST-TAKING HINT: When deciding on an answer for this type of question, the test taker should reason as to which client is stable and which has a potentially higher level of need.

The nurse should teach the client that signs of digoxin toxicity include which of the following? 1.Rash over the chest and back. 2.Increased appetite. 3.Visual disturbances such as seeing yellow spots. 4.Elevated blood pressure.

3 Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with digoxin toxicity.

A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to: 1.Decrease circulatory overload. 2.Improve the myocardial workload. 3.Prevent thrombus formation. 4.Regulate cardiac rhythm.

3 Coumadin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Coumadin does not reduce circulatory load or improve myocardial workload. Coumadin does not affect cardiac rhythm.

The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of doing which of the following? 1.Maintaining a high-fiber diet. 2.Walking 2 miles (3.2 km) every day. 3.Obtaining daily weights at the same time each day. 4.Remaining sedentary for most of the day.

3 Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 lb (0.91 kg) or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an exercise program for the client, such as walking 2 miles (3.2 km) every day, would not be appropriate at discharge. The client's exercise program would need to be planned in consultation with the physician and based on the history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not prescribe an exercise program for the client, a sedentary lifestyle should not be recommended.

In which of the following positions should the nurse place a client with heart failure who has orthopnea? 1.Semisitting (low Fowler's position) with legs elevated on pillows. 2.Lying on the right side (Sims' position) with a pillow between the legs. 3.Sitting upright (high Fowler's position) with legs resting on the mattress. 4.Lying on the back with the head lowered (Trendelenburg's position) and legs elevated.

3 Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg's position.

Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 am, the nurse reviews the following lab tests Potassium 6.8. Which of the following should the nurse do first? 1.Administer the medications. 2.Call the physician. 3.Withhold the captopril. 4.Question the metoprolol dose.

3 The nurse should withhold the dose of captopril; captopril is an ACE-inhibitor and a side effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld.

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit (ICU) via a stretcher. 3. Provide the client going home discharge teaching instructions. 4. Help position the client who is having a portable x-ray done

4 1. Allowing the UAP to take a client down to smoke is not cost effective and is not supportive of the medical treatment regimen that discourages smoking. 2. The client going to the ICU would be unstable, and the nurse should not delegate to a UAP any nursing task that involves an unstable client. 3. The nurse cannot delegate teaching. 4. The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment. TEST-TAKING HINT: The test taker must be knowledgeable about the individual state's Nurse Practice Act regarding what a nurse may delegate to unlicensed assistive personnel. Generally, the answer options that require higher level of knowledge or ability are reserved for licensed staff.

The telemetry nurse notes a peaked T wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess? 1. CK-MB. 2. Troponin. 3. BNP. 4. Potassium

4 1. CK-MB is assessed to determine if the client has had a myocardial infarction. The electrical activity of the heart will not be affected by elevation of this enzyme. 2. Troponin is assessed to determine if the client has had a myocardial infarction. The electrical activity of the heart will not be affected by elevation of this enzyme. 3. Beta-type natriuretic peptide (BNP) is elevated in clients with congestive heart failure, but it does not affect the electrical activity of the heart. 4. Hyperkalemia will cause a peaked T wave; therefore, the nurse should check these laboratory data.

The female client diagnosed with CHF tells the nurse that she has been taking hawthorn extract since the HCP told her that she had heart problems. Which statement by the nurse is most appropriate? 1. "You need to take garlic supplements with hawthorn for it to be effective." 2. "You should stop taking this herb immediately because it can cause more problems." 3. "This herb can cause bleeding if you take it with your other medications." 4. "Some clients find this is helpful, but make sure your HCP is aware of the medication."

4 1. Garlic does not need to be taken for hawthorn to be effective. Both herbs lower blood pressure, so one or the other should be taken. 2. Many clients use herbs, vitamins, and minerals. The nurse should not be judgmental in responses to clients who confi de in the nurse. Doses of ACE inhibitors, cardiac glycosides, and beta blockers may need to be modified if they are taken in combination with some herbs. 3. The herb does not interfere with platelet aggregation or have any anticoagulant effect, so it will not cause bleeding. 4. Hawthorn dilates the peripheral blood vessels, increases coronary circulation, improves cardiac oxygenation, acts as an antioxidant, has a mild diuretic effect, and is used to treat CHF and HTN. Doses of ACE inhibitors, cardiac glycosides, and beta blockers may need to be modifi ed if taken in combination with hawthorn.

Which medication should the nurse question administering? 1. Lisinopril to a client with a blood pressure of 118/84. 2. Carvedilol to a client with an apical pulse of 62. 3. Verapamil to a client with angina. 4. Furosemide to a client reporting leg cramps

4 1. Lisinopril (Zestril) is an ACE inhibitor. The blood pressure is above 90/60, so there is no reason for the nurse to question administering an ACE inhibitor in this situation. 2. Carvedilol (Coreg) is a beta blocker. The apical pulse is above 60 bpm, so the nurse would not question administering a beta blocker in this situation. 3. Verapamil (Calan) is a CCB. CCBs are prescribed to treat angina, so there is no reason for the nurse to question the medication. 4. Furosemide (Lasix) is a loop diuretic. Leg cramps may indicate a low blood potassium level. The nurse should hold the medication until the potassium level can be checked. Loop diuretics cause the kidneys to excrete potassium. Hypokalemia can cause life-threatening dysrhythmias.

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)g sodium diet. 3. Weigh the client daily. 4. Plan for frequent rest periods.

4 1. Measuring the intake and output is an appropriate intervention to implement for a client with CHF, but it does not address getting the client to tolerate activity. 2. Dietary sodium is restricted in clients with CHF, but this is an intervention for decreasing fluid volume, not for increasing tolerance for activity. 3. Daily weighing monitors fluid volume status, not activity tolerance. 4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome. TEST-TAKING HINT: With questions involving nursing diagnoses or goals and outcomes, the test taker should realize that all activities referred to in the answer options may be appropriate for the disease but may not be specific for the desired outcome.

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position

4 1. Sponging dry the client's forehead would be appropriate, but it is not the first intervention. 2. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention. 3. Taking the vital signs would be appropriate, but it is not the first intervention. 4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead. TEST-TAKING HINT: In a question that asks the nurse to set priorities, all the answer options can be appropriate actions by the nurse for a given situation. The test taker should apply some guidelines or principles, such as Maslow's hierarchy, to determine what will give the client the most immediate assistance.

Which laboratory data confirm the diagnosis of congestive heart failure? 1. Chest x-ray (CXR). 2. Liver function tests. 3. Blood urea nitrogen (BUN). 4. Beta-type natriuretic peptide (BNP)

4 1. The CXR will show an enlarged heart, but it is not used to confirm the diagnosis of congestive heart failure. 2. Liver function tests may be ordered to evaluate the effects of heart failure on the liver, but they do not confirm the diagnosis. 3. The BUN is elevated in heart failure, dehydration, and renal failure, but it is not used to confirm congestive heart failure. 4. BNP is a hormone released by the heart muscle in response to changes in blood volume and is used to diagnose and grade heart failure

The nurse should assess the client for digoxin toxicity if serum levels indicate that the client has a: 1.Low sodium level. 2.High glucose level. 3.High calcium level. 4.Low potassium level.

4 A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity.

The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to help: 1.Prevent electrolyte imbalances. 2.Retard rapid drug absorption. 3.Excrete excessive fluids accumulated during the night. 4.Prevent sleep disturbances during the night.

4 When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.

Which of the following sets of conditions is an indication that a client with a history of left-sided heart failure is developing pulmonary edema? Select all that apply. 1.Distended jugular veins. 2.Dependent edema. 3.Anorexia. 4.Coarse crackles. 5.Tachycardia.

4,5 Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.

Lasix (furosemide) 40 mg intravenous push (IVP) is prescribed. Lasix 10 mg/mL is available. The nurse should administer _________________________ mL.

4mL