Chapter 29: Management of Patients With Complications from Heart Disease - ML4
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.
Which is a key diagnostic indicator of heart failure?
Brain natriuretic peptide (BNP) BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. BUN, creatinine, and a CBC are included in the initial workup.
A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next?
Check the client's potassium level. The client is asymptomatic but has had a change in heart rhythm. More information is needed before calling the health care provider. Because the client is taking furosemide, a potassium-wasting diuretic, the next action would be to check the client's potassium level.
The nurse identifies which symptom as a manifestation of right-sided heart failure (HF)?
Congestion in the peripheral tissues
Which medication reverses digitalis toxicity?
Digoxin immune FAB
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.
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 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.
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
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?
Pulmonary congestion When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath
A client with heart failure reports a sudden change in the ability to perceive colors. The client reports nausea, and assessment reveals an irregular pulse of 39 beats per minute. What is the nurse's best action?
Report the possibility of digitalis toxicity to the care provider promptly
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.
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.
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:
canned peas.
The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema?
decreased left ventricular pumping
The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure?
furosemide 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.
A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber?
heart rate of 55 beats per minute Digoxin therapy slows conduction through the AV node. A heart rate of 55 is slow and the digoxin therapy may slow the heart rate further
The critical care nurse is caring for a client with cardiogenic shock. What is the premise for inserting an intra-aortic balloon pump?
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.
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.
The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity?
potassium level of 2.8 mEq/L
A nurse suspects that a client has digoxin toxicity. The nurse should assess for:
vision changes.
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.
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.
The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed?
heart transplant
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.
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
A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be?
30% The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure.The normal EF is 55%-65%
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. A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.
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.
A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action?
Administer epinephrine. PEA can be caused by hypovolemia, hypoxia, hypothermia, hyperkalemia, massive pulmonary embolism, myocardial infarction, and medication overdose (beta blockers, calcium channel blockers). PEA is treated with epinephrine according to advanced life support protocol.
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.
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.
The nurse is teaching a group of clients with heart failure about how to decrease leg edema. What dietary advice will the nurse give to clients with severe heart failure?
Avoid the intake of processed and commercially prepared foods.
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
Echocardiogram
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 heart?'s ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm corpulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart?s conduction system.
The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?
Elevate the head of the bed. The nurse's priority action is to elevate the head of bed to help with breathing. The pulse oximetry reading provides more data, but is not the priority intervention
The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience?
Gradual unexplained weight gain Clients with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention.
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
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.
The student nurse is caring for a client with heart failure. Diuretics have been ordered. What method might be used with a debilitated client to help the nurse evaluate the client''s response to diuretics?
Using a urinary catheter To evaluate response to diuretics, a urinary catheter is used. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output.
A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?
echocardiogram
The nurse is asssessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the 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
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 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.
The nurse is assessing a newly admitted client with chest pain. What medical disorder is most likely causing the client to have jugular vein distention?
heart failure Elevated venous pressure, exhibited as jugular vein distention, indicates the heart's failure to pump.
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
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.
Examine the client's neck for distended veins. 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.
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.
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).
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound?
a third heart sound (S3). An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures.
A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. Which finding indicates a need for immediate attention?
lung congestion Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen or mechanical ventilation is used to support breathing
The nurse is caring for a client with heart failure who is receiving torsemide. What implementation will help the nurse evaluate the client's response of the medication?
measuring intake and output To evaluate response to torsemide, which is a diuretic, intake and output are monitored
The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure?
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. Oliguria is a sign of kidney failure or dehydration.
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).
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
The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart?
echocardiogram
A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment?
moist, gurgling respirations Clients with acute pulmonary edema experience sudden dyspnea, wheezing, orthopnea, cough, cyanosis, and tachycardia. Respirations sound moist or gurgling.
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 . 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.
The nurse is caring for a client with severe compensated heart failure. What human brain natriuretic peptide (BNP) medication may be used in a critical care unit with hemodynamic monitoring?
Natrecor Nesiritide (Natrecor) is a preparation of human BNP that mimics the action of endogenous BNP, causing diuresis and vasodilation, reducing blood pressure, and improving cardiac output.
