Prep U Ch. 29 Management of Patients With Complications from Heart Disease

A patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention?

Assess oxygen saturation leve Assessment is priority to determine severity of the exacerbation. It is important to assess the oxygen saturation level of a heart failure patient, as below normal oxygen saturation level can be life-threatening. Treatment options vary according to the severity of the patient's condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches.

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?

Call for a chest x-ray.

The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?

Echocardiogram

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

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 patient who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly develops complaints of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the patient for other signs and symptoms of which of the following problems?

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 where 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 patient has been diagnosed with systolic heart failure. The nurse would expect the patient's ejection fraction to be at which level?

Severely reduced The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure.

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

The client says his rings have become tight and are difficult to remove.

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

1.25

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

A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD?

An LVAD only supports a failing left ventricle. A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.

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.

Which of the following is a key diagnostic laboratory test for heart failure?

B-type natriuretic peptide

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?

Bibasilar crackles

The nurse recognizes which of the following lab tests is a key diagnostic indicator of heart failure?

Brain natriuretic peptide (BNP)

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 identifies which of the following symptoms as a manifestation of right-sided heart failure (HF)?

Congestion in the peripheral tissues

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.

What is the primary underlying disorder of pulmonary edema?

Decreased left ventricular pumping

Which of the following is a cerebrovascular manifestation of heart failure?

Dizziness

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

Dyspnea on exertion

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

Electrolyte and water loss The nurse should closely monitor a patient being administered diuretics for electrolyte and water loss. Digitalis preparations (not diuretics) are potent and may cause various toxic effects. The nurse should monitor the patient for signs of digitalis toxicity, not just during the initial period of therapy, but throughout care management. However, the effects do not include vasculitis, flexion contractures, or enlargement of joints

A patient with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, bradycardia, and muffled heart sounds. The senior nursing student recognizes these symptoms occur when

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 (eg, compression of the heart).

You are caring for a client with suspected right-sided heart failure. What would you know that clients with suspected right-sided heart failure may experience?

Gradual unexplained weight gain

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

Heart failure 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.

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV

The nurse identifies which of the following symptoms as a characteristic of right-sided heart failure?

Jugular vein distention (JVD)

A new client has been admitted with right-sided heart failure. The nurse knows to look for which of the following assessment findings when assessing this client?

Jugular venous distention

Which of the following 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 patient's symptoms.

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.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately?

Persistent cough Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite should be reported immediately. Weight gain should be reported immediately. Frequent urination, causing interruption of sleep, should be reported immediately.

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which of the following assessment findings for this client?

Pulmonary congestion

The nurse recognizes which of the following symptoms 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 is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure?

Right-sided heart failure

Which is a potassium-sparing diuretic used in the treatment of heart failure?

Spironolactone (Aldactone)

Which of the following is a manifestation of right-sided heart failure?

Systemic venous congestion

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

Which of the following 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).

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.

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating

orthopnea.

A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth daily, and furosemide (Lasix), 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause:

visual disturbances.

On his return to the cardiac step-down unit after his diagnostic procedure, a client awaits the report from his cardiologist. As the client's nurse, you review the process of measuring ejection fraction and explain to the client that it measures the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?

55%

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 has been prescribed furosemide (Lasix) 80 mg twice daily. The cardiac monitor technician informs the nurse that the client has started having rare premature ventricular contractions followed by runs of bigeminy lasting 2 minutes. During the assessment, the nurse determines that the client is asymptomatic and has stable vital signs. Which of the following actions should the nurse perform next?

Check the client's potassium level.

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.

A 76-year-old client has a significant history of congestive heart failure. During his semiannual cardiology examination, for what should you, as his nurse, specifically assess? Select all that apply.

Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he 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.

Which of the following is a key diagnostic indicator of heart failure (HF)?

Brain natriuretic peptide (BNP)

Ronald is a 46-year-old who has developed congestive heart failure. He has to learn to adapt his diet and you are his initial counselor. Which of the following should you tell him to avoid?

Canned peas There are a wide variety of foods that Ronald can still eat. The key is they have 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. The key is to read the food labels and look for foods that contain <300 mg sodium/serving.

The nurse is preparing to administer hydralazine and isosorbide dinitrate (Dilatrate). 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 physician 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 physician.

A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client?

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

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

JVD is noted 3 cm above the sternal angle. JVD is assessed with the patient sitting at a 45° angle. Jugular vein distention greater than 3 cm above the sternal angle is considered abnormal and is indicative of right ventricular 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

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

Leg edema

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

Low serum potassium level

Which of the following medications is a human brain natriuretic peptide (BNP) preparation?

Natrecor Nesiritide (Natrecor) is a preparation of human BNP that mimics the action of endogenous BNP, causing dieresis and vasodilation, reducing blood pressure, and improving cardiac output. It is a preload and afterload reducer. Metoprolol is a beta-blocker. Captopril and enalapril are angiotensin-converting enzyme (ACE) inhibitors.

You are working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for you to closely monitor an older adult receiving digitalis preparations for cardiac disorders?

Older adults are at increased risk for toxicity. Older adults receiving digitalis preparations are at increased risk for toxicity because of the decreased ability of the kidneys to excrete the drug due to age-related changes. The margin between a therapeutic and toxic effect of digitalis preparations is narrow. Using digitalis preparations does not increase the risk of cardiac arrests, hyperthyroidism, or asthma.

The nurse does an assessment on a patient who is admitted with a diagnosis of right-sided heart failure. The nurse knows that a significant sign is which of the following?

Pitting edema The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response.

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

The nurse is preparing to administer furosemide (Lasix) to a client with severe heart failure. What lab study should be of most concern for this client while taking Lasix?

Potassium level of 3.1

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.

Which of the following nursing interventions should a nurse perform when a patient with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta blockers?

Withhold the drug and inform the primary health care provider. Before administering beta blockers, the nurse should monitor the patient's apical pulse. If the heart rate is less than 60 bpm, the nurse should withhold the drug and inform the primary health care provider.

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

Withhold the medication and notify the physician of the heart rate. Digitalis drugs are withheld if the heart rate is less than 60 or more than 120 beats/minute until a physician is consulted. The other choices would have the nurse administer the drug, which would not be the standard of practice.