Med-Surge Nursing Cardio Prep U ch 29

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?

"Are you only able to breathe when you are sitting upright?" 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.

Before discharge, which instruction should a nurse give to a client receiving digoxin?

"Call the physician if your heart rate is above 90 beats/minute." The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate.

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?

"I sleep on three pillows each night." 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.

The nurse is developing a plan of care for a client following pericardiocentesis. Which interventions should the nurse implement? Choose all that apply.

1. Assess vital signs every 15 minutes for the first hour. 2. Monitor heart and lung sounds. 3. Record fluid output. 4. Evaluate the cardiac rhythm. The nurse should monitor the vital signs for any client who has undergone surgery. Because this procedure requires entering the pericardial sac, assessing heart and lung sounds assists in determining heart failure. The pericardial fluid is recorded as output and assessing the cardiac rhythm allows to assess for cardiac failure. The client should be kept in the semi-Fowler's position, not flat.

A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply.

1. Examine the client's neck for distended veins. 2. Monitor the client for signs of lethargy or confusion. During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion. Excess tears are not part of the checklist.

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.)

1. Pulmonary crackles 2. Dyspnea 3. Cough The clinical manifestations of pulmonary congestion associated with left-sided heart failure include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels, but not ascites or jugular vein distention.

A client is receiving furosemide, a loop diuretic, to prevent fluid overload. The order is for 50 mg intraveneous now. The pharmacy supplies furosemide 80 mg per 2 mL. How many mL will the nurse give the client? Enter the correct number ONLY.

1.25 (50 mg/80 mg) x 2 mL = 1.25 mL.

A nurse has come upon an unresponsive, pulseless victim. She has placed a 911 call and begins CPR. The nurse understands that if the patient has not been defibrillated within which time frame, the chance of survival is close to zero?

10 minutes The survival rate decreases for every minute that defibrillation is delayed. If the patient has not been defibrillated within 10 minutes, the chance of survival is close to zero. The other options are too long of a time frame.

A client has had an echocardiogram to measure ejection fracton. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?

55% Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.

The nurse is assigned to care for a patient with heart failure. What classification of medication does the nurse anticipate administering that will improve symptoms as well as increase survival?

ACE inhibitor Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and diuretics (Table 29-3). 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 (Fonarow et al., 2010). Calcium channel blockers are no longer recommended for patients with HF because they are associated with worsening failure

A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The nurse knows that these are symptoms of what?

Acute pulmonary edema Clients with acute pulmonary edema exhibit sudden dyspnea, wheezing, orthopnea, restlessness, cough (often productive of pink, frothy sputum), cyanosis, tachycardia, and severe apprehension. These symptoms do not indicate progressive heart failure, pulmonary hypertension, or cardiogenic shock.

The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains afterload to the student and then asks the student what nursing interventions might cause decreased afterload. The student correctly answers which of the following?

Administration of a vasodilating drug (as ordered by a physician) Afterload is the amount of resistance to the ejection of blood from the ventricles. Anything that decreases this resistance will decrease afterload. Vasodilation will decrease systemic resistance. Antiembolytic stockings and keeping the client's legs elevated will increase resistance.

The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause decreased preload. The student correctly answers which of the following?

Administration of a vasodilating drug (as ordered by a physician) Preload is the amount of blood presented to the ventricles just before systole. Anything that decreases the amount of blood returning to the heart will decrease preload, such as vasodilation or blood pooling in the extremities. Anything that assists in returning blood to the heart (antiembolytic stockings) or preventing blood from pooling in the extremities will increase preload.

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered?

An echocardiogram Increasing shortness of breath (dyspnea) and fatigue are common signs of left-sided heart failure (HF). However, some of the physical signs that suggest HF may also occur with other diseases, such as renal failure and chronic obstructive pulmonary disease; therefore, diagnostic testing is essential to confirm a diagnosis of HF. Assessment of ventricular function is an essential part of the initial diagnostic workup. An echocardiogram is usually performed to determine the ejection fraction, identify anatomic features such as structural abnormalities and valve malfunction, and confirm the diagnosis of HF.

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?

Arterial blood gases In left-sided heart failure, arterial blood gases may be obtained to assess ventilation and oxygenation.

A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?

Assess for elevated blood urea nitrogen levels. Elevated blood urea nitrogen indicates impaired renal perfusion in a client with left-sided heart failure. Serum sodium levels may be elevated. Reduced urine output or elevated blood potassium levels do not indicate impaired renal perfusion in a client with left-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 intervention?

Assess oxygen saturation Assessment is priority 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.

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure?

Atrial fibrillation Cardiac dysrhythmias such as atrial fibrillation may either cause or result from heart failure; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.

The Cardiac Nurse Clinician is teaching a group of clients with heart failure about self-management of their disease. What dietary advice should the Nurse Clinician give to clients with severe heart failure until edema resolves?

Avoid the intake of processed and commercially prepared foods. Until edema resolves, a client with severe heart failure requires restriction of sodium to 500 to 1,000 mg/day. Therefore, processed and commercially prepared foods are eliminated. Vegetables with natural sodium, for example, beets, carrots, and "greens," should be avoided. Fresh, frozen, and canned fruit and fruit juices are not restricted. Increased intake of red meat should not be encouraged; it should be restricted to 6 oz per day.

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?

BP and pulse measurements every 15 to 30 minutes Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.

A health care provider in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?

Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours Pitting edema is documented as a +1 when a depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.

The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse?

Call for help and begin chest compressions. Following the recognition of unresponsiveness, a protocol for basic life support is initiated. This includes activation of the emergency response team for help and performance of high-quality cardiopulmonary resuscitation (CPR), which includes beginning chest compressions.

A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?

Class I (Mild) Class I is when ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.

The nurse is caring for a client in the hospital with chronic heart failure that has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, he becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?

Class III (Moderate) Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class I is ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.

The nurse identifies which symptom as a manifestation of right-sided heart failure (HF)?

Congestion in the peripheral tissues Right-sided HF, failure of the right ventricle, results in congestion in the peripheral tissues and the viscera and causes systemic venous congestion and a reduction in forward flow. Left-sided HF refers to failure of the left ventricle; it results in pulmonary congestion and 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.

A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved?

Decrease in central venous pressure (CVP) A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade.

Which of the following body system responses correlates with systolic heart failure (HF)?

Decrease in renal perfusion A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.

Which medication reverses digitalis toxicity?

Digoxin immune FAB 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 assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?

Dizziness Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion include dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.

Which drug is most commonly used to treat cardiogenic shock?

Dopamine (Intropin) Dopamine, a sympathomimetic drug, is used to treat cardiogenic shock. It increases perfusion pressure to improve myocardial contractility and blood flow through vital organs. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and doesn't have a direct effect on contractility or tissue perfusion. Metoprolol is a beta-adrenergic blocker that slows heart rate and lowers blood pressure, undesirable effects when treating cardiogenic shock.

The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?

Dyspnea on exertion Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia.

The diagnosis of heart failure is usually confirmed by which of the following?

Echocardiogram Although the chest X-ray can indicate cardiomegaly and the ECG can indicate a left ventricular abnormality, it is the echocardiogram that is diagnostic. This test measures ejection fraction (EF) which, if greater than 40% and accompanied with signs and symptoms of heart failure, indicates diastolic dysfunction and impaired ventricular relaxation.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Echocardiogram 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 nursing instructor is discussing heart failure with their clinical group. The instructor talks about heart failure in terms of a decreasing ejection fraction of the heart. What diagnostic test is used to measure the ejection fraction of the heart?

Echocardiogram 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 hearts' ejection fraction.

A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, bradycardia, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence?

Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).

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?

Head of the bed elevated 45 degrees and lower arms supported by pillows 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.

A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?

Heart failure A client with heart failure has decreased cardiac output caused by the heart's decreased pumping ability. A buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. A client with pulmonary embolism experiences acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. A client with cardiac tamponade experiences muffled heart sounds, hypotension, and elevated central venous pressure. A client with tension pneumothorax has a deviated trachea and absent breath sounds on the affected side as well as dyspnea and jugular vein distention.

Which of the following therapies are for patient who have advanced heart failure (HF) after all other therapies have failed?

Heart transplant Heart transplantation involves replacing a person's diseased heart with a donor heart. This is an option for advanced HF patients when all other therapies have failed. A ventricular access device, ICD, and cardiac resynchronization therapy would be tried prior to a heart transplant.

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?

Hold the medication and call the health care provider. 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 patient in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the telemetry monitor. Which of the following is a potential cause of PEA?

Hyperkalemia PEA can be caused by hypovolemia, hypoxia, hypothermia, hyperkalemia, massive pulmonary embolism, myocardial infarction, and medication overdose (beta blockers, calcium channel blockers).

A nurse is discussing cardiac hemodynamics with a nursing student and explains the concept of afterload. The student asks what medical conditions might cause increased afterload. The nurse correctly answers which of the following?

Hypertension and aortic valve stenosis Major factors that determine afterload are the diameter and distensibility of the great vessels (aorta and pulmonary artery) and the opening and competence of the semilunar valves (pulmonic and aortic valves). If the client has significant vasoconstriction, hypertension, or a narrowed vavular opening, resistance or afterload increases. Diabetes mellitus and mitral valve stenosis do not directly affect afterload.

The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity. Under what classification does the nurse understand this patient would be categorized?

II Classification II of heart failure is indicated by the patient being comfortable at rest, but experiencing fatigue, palpitation, or dyspnea during ordinary physical activity.

Which of the following is the primary cause of pulmonary or peripheral congestion?

Inadequate cardiac output 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.

Cardiogenic shock is pump failure that primarily occurs because of which of the following?

Inadequate tissue perfusion The classic signs of cardiogenic shock are related to tissue hypoperfusion and an overall state of shock that is proportional to the extent of left ventricular damage. Reduced cardiac output and stroke volume reduces arterial blood pressure and tissue perfusion.

Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?

Increased pulmonary artery diastolic pressure Increased pulmonary artery diastolic pressure suggests left-sided heart failure. Central venous pressure increases in heart failure rather than decreases. The cardiac index decreases in heart failure. The mean pulmonary artery pressure increases in heart failure.

A nurse reviews the patient's chart. The doctor noted in the progress notes that he suspected the patient was experiencing decreased left ventricular function. The nurse knows to look for documentation of all of the following to validate that diagnosis except:

Increased stroke volume. Decreased left ventricular function would be characterized by a decreased stroke volume because the ventricle has less time to fill due to a rapid and weak heart rate.

What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock?

Intra-aortic balloon pump Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate. Hypothermia-hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for termination of life-threatening ventricular rhythms.

A client in the hospital informs the nurse he "feels like his heart is racing and can't catch his breath." What does the nurse understand occurs as a result of a tachydysrhythmia?

It reduces ventricular ejection volume. Reducing ventricular ejection volume because diastole, during which the ventricle fills withblood (preload), is shortened as a result of a tachydsrhythmia. Causing a loss of elasticity in the muscle is a result of cardiomyopathy. Afterload is decreased not increased.

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?

JVD is noted 4 cm above the sternal angle. JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

Which is a characteristic of right-sided heart failure?

Jugular vein distention Jugular vein distention is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.

The nurse identifies which symptom as a characteristic of right-sided heart failure?

Jugular vein distention (JVD) JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.

The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?

Left ventricular function The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?

Leg edema Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough.

The nurse is preparing a client for a multiple gated acquisition (MUGA) scan. What would be an important instruction for the nurse to give a client who is to undergo a MUGA scan?

Lie very still at intermittent times during the test. The nurse should instruct the client, who is to undergo a MUGA scan, to lie very still at intermittent times during the 45-minute test. The client need not drink plenty of fluids, avoid activities before/after the test, or avoid dairy products during the test.

Which of the following types of diuretic is the first-line treatment for those diagnosed with heart failure (HF)?

Loop Loop diuretics such as furosemide, bumetanide, and torsemide are the preferred first-line diuretics because of their efficacy in patients with and without renal impairment. Diuretics should never be used alone to treat HF because they don't prevent further myocardial damage.

Which feature is the hallmark of systolic heart failure?

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

A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?

Low serum potassium level Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood pressure decreases, blood volume decreases, and urine output increases.

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?

Low-sodium diet 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.

Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?

Monitor blood pressure frequently Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to clients with severe HF, including those who are waiting for a heart transplant. Because the drug causes vasodilation, the client's blood pressure is monitored before administration because if the client is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and after infusions of milrinone.

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate?

Morphine sulfate Morphine seems to help relieve respiratory symptoms by depressing higher cerebral centers, thus relieving anxiety and slowing respiratory rate. Morphine also promotes muscle relaxation and reduces the work of breathing. Furosemide is a loop diuretic and will decrease fluid accumulation but will not reduce anxiety. Nitroglycerin will promote smooth muscle relaxation in the vessel walls and will relieve pain but not reduce anxiety. Dopamine is an inotrope that will increase the force of ventricular contraction but will not alleviate anxiety.

A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)?

Myocardial ischemia Myocardial dysfunction and HF can be caused by a number of conditions, including coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Atherosclerosis of the coronary arteries is a primary cause of HF, and coronary artery disease is found in the majority of clients with HF. Ischemia causes myocardial dysfunction because it deprives heart cells of oxygen and causes cellular damage. MI causes focal heart muscle necrosis, myocardial cell death, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Left-sided heart failure is caused by myocardial ischemia. Ineffective right ventricular contraction, pulmonary embolus, and cystic fibrosis cause right-sided heart failure.

The client with cardiac failure is taught to report which symptom to the physician or clinic immediately?

Persistent cough 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 physician orders digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?

Potassium level of 2.8 mEq/L 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 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?

Potassium level of 3.1 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.

A patient is prescribed digitalis preparations. Which of the following conditions should the nurse closely monitor when caring for the patient?

Potassium levels A key concern associated with digoxin therapy is digitalis toxicity. Clinical manifestations of toxicity include anorexia, nausea, visual disturbances, confusion, and bradycardia. The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?

Preload Preload is the the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from a ventricle. The ejection fraction is the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole. Stroke volume is the amount of blood pumped out of the ventricle with each contraction.

Which of the following would be inconsistent as a lifestyle change directive for the patient diagnosed with heart failure?

Push fluids Lifestyle recommendations include restriction of dietary sodium; avoidance of excessive fluid intake, alcohol, and smoking; weight reduction when indicated; and regular exercise.

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

Respiratory alkalosis At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid, shallow breathing. Later, there is a shift to metabolic acidosis as gas exchange becomes more impaired. Respiratory acidosis and metabolic alkalosis are incorrect distractors.

The nurse recognizes which symptom as a classic sign of cardiogenic shock?

Restlessness and confusion 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 with heart failure has been receiving an intravenous infusion at 150 mL/hr. Now the client is short of breath. The nurse auscultates crackles bilaterally and notes neck vein distention and tachycardia. Using critical thinking skills, what should the nurse do first?

Slow the infusion and notify the physician. The client has fluid overload, so the nurse should first slow the infusion to prevent additional overload, and then notify the physician to obtain further orders. Notifying the physician without slowing the infusion would increase the client's risk. Discontinuing the infusion is not appropriate, because having a vascular access will be important. Administering a diuretic without turning down the intravenous infusion rate is counterproductive.

Which is a manifestation of right-sided heart failure?

Systemic venous congestion 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.

The nurse is administering nitroglycerin, which he knows decreases preload as well as afterload. Preload refers to which of the following?

The amount of blood presented to the ventricles just before systole Preload is the amount of blood presented to the ventricles just before systole. It increases pressure in the ventricles, which stretches the ventricle wall. Like a piece of elastic, the muscle fibers need to be stretched to produce optimal recoil and forceful ejection of blood. Afterload refers to the amount of resistance to the ejection of blood from the ventricle. To eject blood, the ventricles much overcome the resistance caused by tension in the aorta, systemic vessels, and pulmonary artery.

The triage nurse in the Emergency Department (ED) is admitting a client with a history of Class III heart failure. What symptoms would the nurse expect the client to exhibit?

The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. Class III (Moderate): There is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitation, or dyspnea. This makes options A, B, and D incorrect.

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?

The development of left-sided heart failure 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. Corpulmonale is a condition in which the heart is affected secondarily by lung damage.

A nurse is administering lanoxin, which she knows increases contractility as well as cardiac output. Contractility refers to which of the following?

The force of the contraction related to the status of the myocardium Contractility is the force of contraction and is related to the status of the myocardium. Preload is the amount of blood presented to the ventricles just before systole. It increases pressure in the ventricles, which stretches the ventricle wall. Like a piece of elastic, the muscle fibers need to be stretched to produce optimal recoil and forceful ejection of blood. Afterload refers to the amount of resistance to the ejection of blood from the ventricle. To eject blood, the ventricles much overcome the resistance caused by tension in the aorta, systemic vessels, and pulmonary artery.

What is the main difference between Class I and Class II heart failure as defined by the New York Heart Association (NYHA)?

The level of physical activity each allows Both Class I and Class II levels of heart failure are considered Mild under the New York Heart Association (NYHA) guidelines. The difference is that in Class II, the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea, whereas in Class I, the client is comfortable both at rest and during ordinary physical activity. A marked limitation of physical activity would be a sign of Moderate heart failure, and inability to carry out any physical activity is a sign of Severe heart failure.

The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?

There is excess fluid volume in the interstitial space in areas affected by gravity. Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area. The other options are not descriptive of pitting edema.

Which statement best describes the therapeutic action of loop diuretics?

They block sodium reabsorption in the ascending loop and dilate renal vessels. Loop diuretics block sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. They also dilate renal vessels. Although loop diuretics block potassium reabsorption, this isn't a therapeutic action. Thiazide diuretics, not loop diuretics, promote sodium secretion into the distal tubule.

Which treatment is the best therapy for a stable client with digoxin toxicity?

Time and symptomatic treatment Time is the best treatment for stable clients with digoxin toxicity. Their kidneys excrete the metabolites and symptomatic treatment alleviates the rhythm disturbances or nausea caused by the toxicity. Activated charcoal is effective only if the client has taken an overdose of cardiac glycosides and a large amount of unabsorbed drug remains in the GI tract before the serum level increases. Physicians reserve hemodialysis for clients who are extremely unstable despite symptomatic treatment or whose renal function isn't sufficient to excrete the drug. Physicians might use atropine to treat bradycardia that results from digoxin toxicity, but wouldn't necessarily use atropine to treat the toxicity itself.

Which is a classic sign of cardiogenic shock?

Tissue hypoperfusion Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation). Low blood pressure is a classic sign of cardiogenic shock. Hypoactive bowel sounds are classic signs of cardiogenic shock. Decreased urinary output is a classic sign of cardiogenic shock.

The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer?

Valsartan (Diovan) Valsartan (Diovan) is the only angiotensin receptor blocker listed. Digitalis/digoxin (Lanoxin) is a cardiac glycoside. Metolazone (Zaroxolyn) is a thiazide diuretic. Carvedilol (Coreg) is a beta-adrenergic blocking agent (beta-blocker).

A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?

Ventricular assist device (VAD) VADs may be used for one of three purposes: (1) a bridge to recovery, (2) a bridge to transport, or (3) destination therapy (mechanical circulatory support when there is no option for a heart transplant). An implanted cardioverter-defibrillator or pacemaker is not a bridge to transplant and will only correct the conduction disturbance and not the pumping efficiency. An IABP is a temporary, secondary mechanical circulatory pump to supplement the ineffectual contraction of the left ventricle. The IABP is intended for only a few days

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Weighing the client daily at the same time each day Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

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?

acute pulmonary edema. 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 with stage IV heart failure has a living will indicating a ventilator may not be used. The client begins experiencing severe dyspnea. What should the nurse who is caring for this client do?

administer oxygen, morphine, and a bronchodilator for client comfort. A living will is a statement of a client's wishes in the event that a life-threatening illness or injury occurs. The client's comfort should be paramount and the nurse should respect the client's wishes. Morphine, oxygen, and bronchodilators can relieve dyspnea and make the client more comfortable, which will enable the client to breathe more easily. The nurse shouldn't arrange for intubation without the client's consent or ask family members for permission to initiate mechanical ventilation.

When assessing a client with left-sided heart failure, the nurse expects to note:

air hunger. With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.

A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:

canned peas. There is a wide variety of foods that the client can still eat; the key is to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. It is important to read food labels and look for foods that contain less than 300 mg sodium/serving.

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 course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing

decompensated heart failure with pulmonary edema. Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated heart failure with pulmonary edema. These signs can be confused with pneumonia and tuberculosis, however the patient reveals course crackles upon auscultation which is indicitive of pulmonary edema. A patient with acute COPD would have diminished lung sounds bilaterally.

Frequently, what is the earliest symptom of left-sided heart failure?

dyspnea on exertion Dyspnea on exertion is often the earliest symptom of left-sided heart failure.

A nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:

establish unresponsiveness. The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client for breathing while opening the airway, deliver two breaths, and check for a carotid pulse.

A nurse is assessing a client with heart failure. What breath sound is commonly auscultated in clients with heart failure?

fine crackles. Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are typically caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.

A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?

mask Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen is one of the first tools used to fight pulmonary edema. A mask, rather than nasal cannula, is needed to deliver the maximum percentages of oxygen. Intubation is reserved for when respiratory failure occurs. Mechanical ventilation is applied once respiratory failure occurs.

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?

nausea and vomiting 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.

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective?

peripheral edema Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what action should the nurse perform?

place the client in high Fowler's position The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase oxygen content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." What additional assessment information would be important for the CSU nurse to obtain?

pulmonary crackles High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.

A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of

pulmonary embolism. Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because:

the client is going into cardiogenic shock. This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.

A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?

visual disturbances. Digoxin toxicity may cause visual disturbances (e.g., flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (e.g., headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (e.g., abnormal heart rate, arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.

A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?

weight. Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.