Heart failure
What is the major goal of nursing care for a client with heart failure and pulmonary edema? Increase cardiac output. Improve respiratory status. Decrease peripheral edema. Enhance comfort.
Increase cardiac output. 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.
A client with chronic heart failure has atrial fibrillation and is taking warfarin. What should the nurse tell the client about the expected outcome of this drug? "This medication will decrease the extra fluid your heart is circulating." "This medication will improve the work of your heart." "This medication will prevent a clot from forming." "This medication will regulate the rhythm of your heart."
"This medication will prevent a clot from forming." Warfarin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (<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. Warfarin does not reduce circulatory load or improve myocardial workload. Warfarin does not affect cardiac rhythm.
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? 5 to 10 minutes 30 to 60 minutes 2 to 4 hours 6 to 8 hours
5 to 10 minutes 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 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? Assess respiratory status. Draw blood for laboratory studies. Insert a Foley catheter. Weigh the client.
Assess respiratory status. 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 teaches a client with heart failure to take oral furosemide in the morning. What is the expected outcome for taking this drug in the morning? The client will: Avoid concentrated urine. Prevent the risk of falling. Limit the excretion of electrolytes. Obtain more sleep more.
Obtain more sleep more. 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 will be able to sleep more. The client may be at risk for falling, and the nurse should instruct all clients to rise from a sitting or lying position slowly, but the primary reason for taking the drug in the morning is to limit the number of times the client would need to void during the night if the drug were taken at bedtime. Taking 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.
A client with heart failure is taking furosemide, digoxin, 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. What other sign should the nurse assess next? hyperkalemia digoxin toxicity fluid deficit pulmonary edema
digoxin toxicity 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.
Which position is best for a client with heart failure who has orthopnea? semisitting (low Fowler's position) with legs elevated on pillows lying on the right side (Sims' position) with a pillow between the legs sitting upright (high Fowler's position) with legs resting on the mattress lying on the back with the head lowered (Trendelenburg's position) and legs elevated
sitting upright (high Fowler's position) with legs resting on the mattress 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.
The nurse should teach the client that signs of digoxin toxicity include: rash over the chest and back. increased appetite. visual disturbances such as seeing yellow spots. elevated blood pressure.
visual disturbances such as seeing yellow spots. 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.
An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. During admission, what should the nurse assess first? blood pressure skin breakdown serum potassium level urine output
blood pressure 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.
Which food should the nurse teach a client with heart failure to limit when following a 2-g sodium diet? apple canned tomato juice whole wheat bread hamburger
canned tomato juice 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 nurse should teach the client to read labels carefully. Apples and whole wheat breads are not high in sodium. Hamburger would have less sodium than canned foods or tomato juice.
The nurse is assessing a client with a known history of chronic heart failure.Which finding indicates poor perfusion to the tissues? blood pressure 102/64 mm Hg cool, pale extremities heart rate 104 bpm shortness of breath when supine
cool, pale extremities In heart failure, the heart is unable to adequately meet the body's metabolic demands; in an attempt to supply major organs, less blood is circulated to extremities, leaving them cool, pale and potentially cyanotic. A blood pressure of 102/64 mm Hg is lower than average, but it may be normal for this client and would not indicate poor perfusion to tissues. It is not unusual for the client with heart failure to have a slightly elevated heart rate (unless taking medications to lower the heart rate) because the increased rate may help compensate for reduced stroke volume (and therefore, decreased cardiac output). Shortness of breath may occur with heart failure as a result of poor pumping action of the heart that allows fluid to accumulate in the lungs, however, it is not an indicator of peripheral perfusion.
What instruction should the nurse's discharge teaching plan for the client with heart failure include? maintaining a high-fiber diet walking 2 miles (3.2 km) every day obtaining daily weights at the same time each day remaining sedentary for most of the day
obtaining daily weights at the same time each day 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 health care provider (HCP) 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 HCP 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.
A client was admitted with an exacerbation of heart failure breath at 0200. At 0700, which information is most important for the nurse who admitted the client to communicate during the hand-off of care report to the nurse who will next take care of the client? admission weight of 210 lb (95 kg) elevated B-type natriuretic peptide of 600 mg/mL reaching 250 mL by incentive spirometer urinary output of 120 mL
urinary output of 120 mL The urinary output is less than the expected minimum of 30 mL/h, and if the urinary output does not increase, the nurse who will next care for the client should report the decreased urinary output to the health care provider. An elevated B-type natriuretic peptide level is expected with acute heart failure. The level that the client can reach with the incentive spirometer is good to know, but it is not the most essential finding to report at this time. The admission weight is helpful only if a prior or baseline weight is also provided.
