Heart Failure (Med Surg- Semester 2)

What should the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure?

Answer: Hypotension and tachycardia. Rationale: Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

At a clinic visit, the nurse provides dietary teaching for a patient recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement?

Answer: "I will limit the amount of milk and cheese in my diet." Rationale: Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt should not be added during food preparation or at the table. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake. Foods labeled as reduced sodium contain at least 25% less sodium than regular.

An older adult patient with chronic heart failure (HF) and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed to continue at home. What is the best response by the nurse?

Answer: "The medication prevents blood clots from forming in your heart." Rationale: Chronic HF causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors.

A patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first?

Answer: Assist the patient to a sitting position with arms on the overbed table. Rationale: The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.

The nurse is preparing to administer a nitroglycerin patch to a patient. When providing teaching about the use of the patch, what should the nurse include?

Answer: Avoid drugs to treat erectile dysfunction. Rationale: The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. NSAIDs do not pose a risk in combination with nitrates. There is no need to take an H2-receptor blocker or increase the dietary intake of high-potassium foods.

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure?

Answer: Blood Pressure Rationale: Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.

An asymptomatic patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before dangling the patient on the bedside, what should the nurse assess first?

Answer: Blood Pressure Rationale: The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas exchange.

A patient is scheduled for a heart transplant. What is a major cause of death beyond the first year after a heart transplant?

Answer: Cardiac vasculopathy Rationale: Beyond the first year after a heart transplant, cancer (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient's risk of an infection.

A patient with a long-standing history of heart failure recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient?

Answer: Choose interventions to promote comfort and prevent suffering. Rationale: The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not used in the care of hospice patients.

The nurse is administering a dose of Digitalis (digoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom?

Answer: Loss of appetite Rationale: Anorexia, nausea, vomiting, blurred or yellow vision, and dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix). What outcome would demonstrate medication effectiveness?

Answer: Reduction of preload. Rationale: Diuretics such as furosemide are used in the treatment of heart failure to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.

After having a myocardial infarction (MI), the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108 beats/min. What should the nurse suspect is happening?

Answer: Right-sided HF Rationale: An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

The nurse prepares to administer digoxin 0.125 mg to a patient admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication?

Answer: Serum potassium level. Rationale: Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity. Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit would not require holding the digoxin dose.

The home care nurse visits a patient with chronic heart failure. Which assessment findings would indicate acute decompensated heart failure (pulmonary edema)?

Answer: Severe dyspnea and blood-streaked, frothy sputum Rationale: Manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths/min, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to acute decompensated heart failure (ADHF)?

Answer: Take medication as prescribed. Rationale: The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What is the priority action by the nurse?

Answer: Withhold the dose and report the potassium level. Rationale: The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and wait for the potassium level to normalize. The provider may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

A patient admitted with heart failure is anxious and reports shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety? (Select all that apply.)

Answers: -Administer ordered morphine sulfate. -Position patient in a semi-Fowler's position. -Instruct patient on the use of relaxation techniques. -Use a calm, reassuring approach while talking to patient. Rationale: Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient? (Select all that apply.)

Answers: -Left ventricular function is documented -Prescription for angiotensin-converting enzyme inhibitor at discharge. -Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen Rationale: The Joint Commission has identified these 3 core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.