Chapter 34 Heart failure EXAM

A compensatory mechanism involved in heart failure that leads to inappropriate fluid retention and additional workload of the heart is: A. Ventricular dilation. B. Ventricular hypertrophy. C. Neurohormonal response. D. Sympathetic Nervous System activation.

Answer: C. Neurohormonal response.

20. Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a. O2 saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Heart rate of 106 beats/min d. Urine output of 50 mL over 2 hours

: A A decrease in O2 saturation to less than 92% indicates hypoxemia, and the nurse should start supplemental O2 immediately. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output may also indicate worsening heart failure and require nursing actions, but the low O2 saturation rate requires the most immediate nursing action.

18. A patient in the intensive care unit who has acute decompensated heart failure (ADHF) reports severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been prescribed for the patient. Which action should the nurse take first? a. Give PRN IV morphine sulfate 4 mg. b. Give PRN IV diazepam (Valium) 2.5 mg. c. Increase nitroglycerin infusion by 5 mcg/min. d. Increase dopamine infusion by 2 mcg/kg/min.

: A Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

17. A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. What is the nurse's priority action? a. Teach the patient about restricting dietary sodium. b. Assess the patient for manifestations of acute heart failure. c. Ask the patient about the use of the prescribed medications. d. Have the patient recall the dietary intake for the past 3 days.

: B The 5-lb weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

3. Which topic will the nurse plan to include in discharge teaching for a patient who has heart failure with reduced ejection fraction (HFrEF)? a. Need to begin an aerobic exercise program several times weekly b. Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors c. Use of salt substitutes to replace table salt when cooking and at the table d. Importance of making an annual appointment with the health care provider

: B The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction below 40% should receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure. Salt substitutes are not usually recommended because of the risk of hyperkalemia. The patient will need to see the primary care provider more often than annually.

19. After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first? a. A patient who reported dizziness after receiving the first dose of captopril. b. A patient who has new-onset confusion and restlessness and cool, clammy skin. c. A patient who is receiving oxygen and has crackles bilaterally in the lung bases. d. A patient who is receiving IV nesiritide (Natrecor), with a blood pressure of 100/62.

: B The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.

24. After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58. b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L. c. Patient who is taking captopril and has a frequent nonproductive cough. d. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache.

: B The patient's low potassium level increases the risk for digoxin toxicity and potentially life-threatening dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their drugs, but their symptoms do not indicate potentially life-threatening complications.

23. A patient who is receiving dobutamine for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)? a. Teach the patient the reasons for remaining on bed rest. b. Change the peripheral IV site according to agency policy. c. Monitor the patient's blood pressure and heart rate every hour. d. Titrate the dobutamine to keep the systolic blood pressure >90 mm Hg.

: C An experienced LPN/VN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, adjusting the drip rate for vasoactive drugs, and inserting a new peripheral IV catheter require RN level education and scope of practice.

12. Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram

: C B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A 12-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

14. A patient with chronic heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. "I plan to take the medication with food." b. "I should eat more potassium-rich foods." c. "I will call for help when I need to get up to use the bathroom." d. "I can expect to feel more short of breath for the next few days."

: C Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of -adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

11. A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is an option. Which response is accurate? a. "Your heart failure has not reached the end stage yet." b. "You could not manage the multiple complications of that surgery." c. "The suitability of a heart transplant for you depends on many factors." d. "Because you have diabetes, you would not be a heart transplant candidate."

: C Indications for a heart transplant include end-stage heart failure (stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Patients with diabetes who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, there are no data to suggest that the patient could not manage the care.

8. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Which instruction should the nurse include? a. Limit dietary sources of potassium. b. Take the hydrochlorothiazide at bedtime. c. Notify the health care provider if nausea develops. d. Take the digoxin if the pulse is below 60 beats/min.

: C Nausea is a symptom of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60 beats/min, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

5. A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" How should the nurse document this finding? a. Orthopnea b. Pulsus alternans c. Paroxysmal nocturnal dyspnea d. Acute bilateral pleural effusion

: C Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alteration of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

4. IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. Which reassessment finding during the first hours of administration indicates that the nurse should decrease the rate of nitroprusside infusion? a. Ventricular ectopy b. Dry, hacking cough c. Systolic BP below 90 mm Hg d. Heart rate below 50 beats/min

: C Sodium nitroprusside is a potent vasodilator and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

9. While admitting an 82-yr-old patient with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." What should the nurse include in the discharge plan? a. Consult with a psychologist. b. Transfer to a long-term care facility. c. Referral to a home health care agency. d. Arrangements for around-the-clock care.

: C The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care.

1. While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate? a. Decreased fluid volume b. Jugular vein atherosclerosis c. Increased right atrial pressure d. Incompetent jugular vein valves

: C The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

16. A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse take first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds. d. Ask about the patient's allergies.

: C This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) may be occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

7. When teaching a patient with heart failure on a 2000-mg sodium diet, which foods should the nurse recommend limiting? a. Chicken and eggs b. Canned and frozen fruits c. Yogurt and milk products d. Fresh or frozen vegetables

: C Yogurt and milk products (e.g., cheese) naturally contain a significant amount of sodium, and the intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. The other foods listed have minimal levels of sodium and can be eaten without restriction.

10. Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. What medication topic should the nurse anticipate including in discharge teaching? a. Beta-Adrenergic blockers b. Calcium channel blockers c. Digitalis and potassium therapy regimen d. Angiotensin-converting enzyme (ACE) inhibitors

: D ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other drugs such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The -adrenergic blockers are not used as initial therapy for new onset heart failure.

15. A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. captopril (Capoten) 25 mg b. furosemide (Lasix) 60 mg c. digoxin (Lanoxin) 0.125 mg d. carvedilol (Coreg) 3.125 mg

: D Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other drugs are appropriate for the patient with ADHF.

6. Which statement by a patient with newly diagnosed heart failure indicates to the nurse that teaching was effective? a. "I will take furosemide (Lasix) every day just before bedtime." b. "I will use the nitroglycerin patch whenever I have chest pain." c. "I will use an additional pillow if I am short of breath at night." d. "I will call the clinic if my weight goes up 3 pounds in a week."

: D Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 lb in 2 days or 3 to 5 lb in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as needed" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops rather than just compensating by further elevating the head of the bed.

22. An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? a. 2+ bilateral pedal edema b. Heart rate of 52 beats/min c. Report of increased fatigue d. Blood pressure (BP) of 88/42 mm Hg

: D The patient's BP indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of -adrenergic blockade, though it may need to be monitored. -Adrenergic blockade initially will worsen symptoms of heart failure in many patients and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

A patient with Chronic heart failure (CHF) and Afib is treated with low-dose digitalis and a loop diuretic. What does the nurse need to do to prevent complications of this drug combination? SATA a. Monitor serum potassium levels b. Teaching the patient how to take a pulse rate c. Withhold digitalis if pulse rhythm is irregular d. Keep an accurate measure of I&O e. Teach the patient about dietary potassium restrictions

A, B a. Monitor serum potassium levels b. Teaching the patient how to take a pulse rate

Which statements accurately describe heart failure with preserved ejection fraction (HFpEF)? SATA a. Uncontrolled hypertension is the primary cause b. Left ventricular ejection fraction may be within normal limits c. The pathophysiology involves ventricular relaxation and filling d. Multiple evidence based therapies have been shown to decrease mortality e. Therapies focus on symptom control and treatment of underlying conditions

A, B, C, E a. Uncontrolled hypertension is the primary cause b. Left ventricular ejection fraction may be within normal limits c. The pathophysiology involves ventricular relaxation and filling e. Therapies focus on symptom control and treatment of underlying conditions

13. Which action should the nurse include in the plan of care for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Teach patient to drink at least 3 liters of fluid daily. d. Titrate nesiritide dose down slowly before stopping.

ANS: A Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Because the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration. Excessive hydration could exacerbate ADHF.

2. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. Weight loss of 2 lb in 24 hours b. Hourly urine output greater than 60 mL c. Reduced dyspnea with the head of bed at 30 degrees d. Patient denies experiencing chest pain or chest pressure

ANS: C Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data may also indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient's response.

21. A patient who has heart failure has recently started taking digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1+ to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

ANS: C Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions) and potentiate the actions of digoxin. Hypokalemia also increases the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? A. Urine output B. Lung sounds C. Blood pressure D. Respiratory rate

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

The nurse recognizes that primary manifestations of systolic failure include: A. Decreased EF and increased PAWP. B. Decreased PAWP and increased EF. C. Decreased pulmonary hypertension associated with normal EF. D. Decreased afterload and decreased left-ventricular end-diastolic pressure.

Answer: A. Decreased EF and increased PAWP.

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? A. Reduce preload. B. Decrease afterload. C. Increase contractility. D. Promote vasodilation.

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

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to ADHF? A. Take medications as prescribed. B. Use oxygen when feeling short of breath. C. Only ask the physician's office questions. D. Encourage most activity in the morning when rested.

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

A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. What should this patient be taught to avoid? A. High-potassium foods B. Drugs to treat erectile dysfunction C. Nonsteroidal antiinflammatory drugs D. Over-the-counter H2 -receptor blockers

Answer: B. Drugs to treat erectile dysfunction. Rational: The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. High-potassium foods, NSAIDs, and H2-receptor blockers do not pose a risk in combination with nitrates.

What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with heart failure? A. Acute anxiety B. Hypotension and tachycardia C. Peripheral edema and weight gain D. Paroxysmal nocturnal dyspnea (PND)

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

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? A. Withhold the daily dose until the following day. B. Withhold the dose and report the potassium level. C. Give the digoxin with a salty snack, such as crackers. D. Give the digoxin with extra fluids to dilute the sodium level.

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

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? A. Muscle aches B. Constipation C. Pounding headache D. Anorexia and nausea

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

A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside, what should the nurse assess first? A. Urine output B. Heart rhythm C. Breath sounds D. Blood pressure

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

Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? A. Infection B. Acute rejection C. Immunosuppression D. Cardiac vasculopathy

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

A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? A. Taper the patient off his current medications. B. Continue education for the patient and his family. C. Pursue experimental therapies or surgical options. D. Choose interventions to promote comfort and prevent suffering.

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

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? A. ADHF B. Chronic HF C. Left-sided HF D. Right-sided HF

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

A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? A. Administer ordered morphine sulfate. B. Position patient in a semi-Fowler's position. C. Position patient on left side with head of bed flat. D. Instruct patient on the use of relaxation techniques. E. Use a calm, reassuring approach while talking to patient.

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

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply)? A. Left ventricular function is documented. B. Controlling dysrhythmias will eliminate HF. C. Prescription for digoxin (Lanoxin) at discharge. D. Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge. E. Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen.

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

A PT with chronic HF and atrial fibrillation is treated with a digitalis glycoside and a loop diuretic. To prevent possible complications of this combination of drugs, what does the nurse need to do? (Select all that apply): A. Monitor serum potassium levels. B. Teach PT how to take a pulse rate. C. Keep an accurate measure of intake and output. D. Teach the PT about dietary restriction of potassium. E. Withhold digitalis and notify health care provider if heart rate is irregular.

Answers: A. monitor serum potassium levels, B. teach PT how to take a pulse.

PT's with a heart transplantation are at risk for which complications in the first year after transplantation? (Select all that apply): A. Cancer. B. Infection. C. Rejection. D. Vasculopathy. E. Sudden cardiac death.

Answers: B. Infection, C. Rejection, E. Sudden cardiac death.

You are caring for a PT with ADHF who is receiving IV dobutamine (Dobutrex). You notice that this drug is ordered because it (Select all that apply): A. Increases SVR. B. Produces diuresis. C. Improves contractility. D. Dilates renal blood vessels. E. Works on the B1-receptors in the heart.

Answers: C. Improves contractility, E. Works on the B1-receptors in the heart.

Patients are at risk for which complication sin the first year after heart transplantation? SATA a. Cancer b. Infection c. Rejection d. Vasculopathy e. Sudden cardiac death

B, C, E Infection, rejection, sudden cardiac death

The nurse is caring for a patient with acute decompensated heart failure who is receiving IV dobutamine. Why would this drug be prescribed? SATA a. It dilates renal blood vessels b. It will increase the heart rate c. Heart contractility will improve d. Dobutamine is a selective beta agonist e. It increases systemic vascular resistance

C, D Heart contractility will improve; it is a selective B-agonist

What compensatory mechanism involved in both chronic heart failure and acute decompensated heart failure leads to fluid retention and edema? a. Ventricular dilation b. Ventricular hypertrophy c. Increased systemic blood pressure d. Renin-angiotensin-aldosterone (RAAS) activation

D Renin-angiotensin-aldosterone (RAAS) activation

Which statements accurately describe heart failure (HF) (select all that apply)? a. A common cause of diastolic failure is left ventricular dysfunction. b. A primary risk factor for heart failure is coronary artery disease (CAD). c. Systolic heart failure results in a normal left ventricular ejection fraction. d. Systolic failure is characterized by abnormal resistance to ventricular filling. e. Hypervolemia precipitates heart failure by decreasing cardiac output and increasing oxygen consumption.

a, b. Diastolic failure is characterized by abnormal resistance to ventricular filling. Hypertension, coronary artery disease (CAD), advanced age, and diabetes are all risk factors for heart failure (HF). Ejection fraction (EF) is decreased in systolic HF. Decreased cardiac output (CO) and increased workload and oxygen requirements of the myocardium precipitate HF due to left ventricle dysfunction.

The patient with chronic heart failure is being discharged with a diuretic, a renin-angiotensin-aldosterone system (RAAS) inhibitor, and a β-adrenergic blocker. When received from the pharmacy, which medication should not be included for this patient? a. Dopamine b. Losartan (Cozaar) c. Carvedilol (Coreg) d. Hydrochlorothiazide

a. Dopamine is a β-adrenergic agonist that is a positive inotrope given IV, not orally, and used for acute HF. Losartan (Cozaar) is an angiotensin II receptor blocker used for patients who do not tolerate angiotensin- converting enzyme (ACE) inhibitors. Carvedilol (Coreg) is the β-adrenergic blocker that blocks the sympathetic nervous system's negative effects on the failing heart. Hydrochlorothiazide is the diuretic.

Which initial physical assessment finding would the nurse expect to be present in a patient with acute left-sided heart failure? a. Bubbling crackles and tachycardia. b. Hepatosplenomegaly and tachypnea. c. Peripheral edema and cool, diaphoretic skin. d. Frothy, blood-tinged sputum and distended jugular veins.

a. Early clinical manifestations of acute left-sided HF are those of interstitial edema, with bubbling crackles and tachycardia, as well as tachypnea. Later frothy, blood- tinged sputum; severe dyspnea; and orthopnea develop with alveolar edema. Severe tachycardia and cool, clammy skin are present as a result of stimulation of the SNS from hypoxemia. Systemic edema reflected by jugular vein distention, peripheral edema, and hepatosplenomegaly are characteristic of right-sided heart failure.

The nurse plans long-term goals for the patient who has had a heart transplant with the knowledge that what is the most common cause of death in heart transplant patients during the first year? a. Infection b. Heart failure c. Embolization d. Malignant conditions

a. In the first year after transplant, with the need for long-term immunosuppressant therapy to prevent rejection, the patient with a transplant is at high risk for infection, a leading cause of death in transplant patients. Acute rejection episodes may also cause death in patients with transplants, but many can be treated successfully with augmented immunosuppressive therapy. Malignancies occur in patients with organ transplants after taking immunosuppressants for a number of years.

The health care provider prescribes spironolactone (Aldactone) for the patient with chronic heart failure. What diet modifications related to the use of this drug should the nurse include in the patient teaching? a. Decrease both sodium and potassium intake. b. Increase calcium intake and decrease sodium intake. c. Decrease sodium intake and increase potassium intake. d. Decrease sodium intake by using salt substitutes for seasoning.

a. Spironolactone is a potassium-sparing diuretic, and when it is the only diuretic used in the treatment of heart failure, moderate to low levels of potassium intake should be maintained to prevent development of hyperkalemia. Sodium intake is usually reduced to at least 2400 mg/day in patients with heart failure, but salt substitutes cannot be freely used because many contain high concentrations of potassium. Calcium intake is not increased.

Priority Decision: The nurse reviews the following vital signs recorded by an unlicensed assistive personnel (UAP) on a patient with acute decompensated heart failure (ADHF): BP 98/60, HR 102 bpm, RR 24, temp 98.2° F (36.7° C), SpO2 84% on 2 L/min via nasal cannula. a. Which of these findings is of highest priority? b. What should the nurse do next?

a. SpO2 of 84% on 2 L/min via nasal cannula indicates impaired oxygen saturation. The patient is having trouble with gas exchange. Airway and breathing are the priority (follow ABCs). b. The nurse should place the patient in high Fowler's position, assess the patient immediately, recheck SpO2, auscultate breath sounds, assess level of consciousness (LOC), check the oxygen connection and rate setting (2 L/min), and talk with the patient about her or his breathing.

In the patient with heart failure, which medications or treatments require careful monitoring of the patient's serum potassium level to prevent further cardiac dysfunction (select all that apply)? a. Enalapril (Vasotec) b. Furosemide (Lasix) c. Nesiritide (Natrecor) d. Spironolactone (Aldactone) e. Metoprolol CR/XL (Toprol XL)

b, d. Furosemide is a diuretic that eliminates potassium and spironolactone is a potassium-sparing diuretic that retains potassium. The other treatments and medications are used for patients with HF, but they do not directly affect serum potassium levels.

Priority Decision: A patient with chronic heart failure is treated with hydrochlorothiazide, digoxin, and lisinopril. To prevent the risk of digitalis toxicity with these drugs, what is most important that the nurse monitor for this patient? a. Heart rate (HR) b. Potassium levels c. Blood pressure (BP) d. Gastrointestinal function

b. Hypokalemia is one of the most common causes of digitalis toxicity because low serum potassium levels enhance ectopic pacemaker activity. When a patient is receiving potassium-losing diuretics, such as hydrochlorothiazide or furosemide, it is essential to monitor the patient's serum potassium levels to prevent digitalis toxicity. Monitoring the heart rate (HR) assesses for complications related to digoxin but does not prevent toxicity.

What is the pathophysiologic mechanism that results in the pulmonary edema of left-sided heart failure? a. Increased right ventricular preload. b. Increased pulmonary hydrostatic pressure. c. Impaired alveolar oxygen and carbon dioxide exchange. d. Increased lymphatic flow of pulmonary extravascular fluid

b. In left-sided HF, blood backs up into the pulmonary veins and capillaries. This increased hydrostatic pressure in the vessels causes fluid to move out of the vessels and into the pulmonary interstitial space. When increased lymphatic flow cannot remove enough fluid from the interstitial space, fluid moves into the alveoli, resulting in pulmonary edema and impaired alveolar oxygen and carbon dioxide exchange. Initially the right side of the heart is not involved.

A patient with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction (LVEF) of 18%. To decrease the risk of complications from these conditions, what drug does the nurse anticipate giving? a. Diuretic b. Anticoagulant c. β-Adrenergic blocker d. Potassium supplement

b. Thrombus formation occurs in the heart when the chambers do not contract normally and empty completely. Both atrial fibrillation and very low left ventricular output (LVEF <20%) lead to thrombus formation, which is treated with anticoagulants to prevent the release of emboli into the circulation as well as antidysrhythmics or cardioversion to control atrial fibrillation.

What describes the action of the natriuretic peptides and nitric oxide in their counterregulatory processes in response to heart failure (HF)? a. Excretion of potassium b. Increased release of ADH c. Vasodilation and decreased blood pressure (BP) d. Decreased glomerular filtration rate and edema

c. Both the natriuretic peptides and nitric oxide contribute to vasodilation, decreased BP, and decreased afterload. The natriuretic peptides also increase excretion of sodium by increasing glomerular filtration rate and diuresis (renal effects) as well as interfere with ADH release and inhibit aldosterone and renin secretion (hormonal effects).

Priority Decision: A patient is admitted to the emergency department with ADHF. Which IV medication would the nurse expect to administer first? a. Digoxin (Lanoxin) b. Morphine sulfate c. Nesiritide (Natrecor) d. Bumetanide (Bumex)

c. Nesiritide (Natrecor) is a recombinant form of a natriuretic peptide that decreases preload and afterload by reducing pulmonary artery wedge pressure (PAWP) and systolic BP, which decreases the workload of the heart for short-term emergency treatment of acute decompensated heart failure (ADHF). Digoxin requires a loading dose and time to work, so it is not recommended for emergency treatment of ADHF. Morphine sulfate relieves dyspnea but has more adverse effects. Bumetanide (Bumex) will decrease fluid volume but also will decrease potassium levels and activate the sympathetic nervous system and RAAS, which can exacerbate HF symptoms.

A 2400-mg sodium diet is prescribed for a patient with chronic heart failure. The nurse recognizes that additional teaching is necessary when the patient makes which statement? a. "I should limit my milk intake to 2 cups a day." b. "I can eat fresh fruits and vegetables without worrying about sodium content." c. "I can eat most foods as long as I do not add salt when cooking or at the table." d. "I need to read the labels on prepared foods and medicines for their sodium content."

c. Not adding salt to foods will not eliminate enough sodium for the 2400-mg sodium diet. All foods that are high in sodium should be eliminated in a 2400-mg sodium diet, in addition to the elimination of salt during cooking. Examples include obviously salted foods as well as unexpected sodium sources that are identified by reading the label of prepared foods and medicines.

The nurse determines that treatment of heart failure has been successful when the patient experiences a. weight loss and diuresis. b. warm skin and less fatigue. c. clear lung sounds and decreased HR. d. absence of chest pain and improved level of consciousness (LOC).

c. Successful treatment of heart failure is indicated by an absence of symptoms of pulmonary edema and hypoxemia, such as clear lung sounds and a normal HR. Weight loss and diuresis, warm skin, less fatigue, and improved LOC may occur without resolution of pulmonary symptoms. Chest pain is not a common finding in heart failure unless coronary artery perfusion is impaired.

Which diagnostic test is most useful in differentiating dyspnea related to pulmonary effects of heart failure from dyspnea related to pulmonary disease? a. Exercise stress testing. b. Cardiac catheterization. c. B-type natriuretic peptide (BNP) levels. d. Determination of blood urea nitrogen (BUN)

c. b-type natriuretic peptide (BNP) is released from the ventricles in response to increased blood volume in the heart and is a good marker for heart failure. If BNP is elevated, shortness of breath is due to heart failure; if BNP is normal, dyspnea is due to pulmonary disease. BNP opposes the actions of the RAAS, resulting in vasodilation and reduction in blood volume. Exercise stress testing and cardiac catheterization are more important tests to diagnose coronary artery disease, and although the blood urea nitrogen (BUN) may be elevated in heart failure, it is a reflection of decreased renal perfusion. (See Table 31-6.)

The nurse monitors the patient receiving treatment for acute decompensated heart failure with the knowledge that marked hypotension is most likely to occur with the IV administration of which medication? a. Milrinone b. Furosemide c. Nitroglycerin d. Nitroprusside

d. Although all of these drugs may cause hypotension, nitroprusside is a potent dilator of both arteries and veins and may cause such marked hypotension that an inotropic agent (e.g., dobutamine) administration may be necessary to maintain the BP during its administration. Furosemide may cause hypotension because of diuretic-induced depletion of intravascular fluid volume. Milrinone has a positive inotropic effect in addition to peripheral vasodilation. Nitroglycerin is a vasodilator and can decrease BP but not as severely as nitroprusside. It primarily dilates veins and increases myocardial oxygen supply.

The acronym FACES is used to help teach patients to identify early symptoms of heart failure. What does this acronym mean? a. Frequent activity leads to cough in the elderly and swelling b. Factors of risk: activity, cough, emotional upsets, salt intake c. Follow activity plan, continue exercise, and know signs of problems d. Fatigue, limitation of activities, chest congestion/cough, edema, shortness of breath

d. FACES is used to teach patients to identify early HF symptoms. F = Fatigue; A = Activity limitations; C =Chest congestion/cough; E = Edema; S = Shortness of breath. The other options are not correct.

Which statement by the patient with chronic heart failure should cause the nurse to determine that additional discharge teaching is needed? a. "I will call my health clinic if I wake up breathless at night." b. "I will look for sodium content on labels of foods and over-the-counter medicines." c. "I plan to organize my household tasks so I don't have to constantly go up and down the stairs." d. "I should weigh myself every morning and go on a diet if I gain more than 2 or 3 pounds in 2 days."

d. Further teaching is needed if the patient believes a weight gain of 2 to 3 pounds in 2 days is an indication for dieting. In a patient with heart failure, this type of weight gain reflects fluid retention and is a sign of heart failure that should be reported to the HCP. The other options show patient understanding of the heart failure management teaching (see Table 34-10).

Which medication shows improvement in HF for African American patients for hypertension and angina? a. Captopril b. Nitroglycerin c. Spironolactone (Aldactone) d. Isosorbide dinitrate and hydralazine (BiDil)

d. Isosorbide dinitrate and hydralazine (BiDil) is recommended for use in African American patients with HF to treat hypertension and angina. Captopril is used for hypertension by all patients. Nitroglycerin is used with hydralazine for patients who cannot tolerate RAAS inhibitors (ACE inhibitors or ARBs) for heart failure management. Spironolactone (Aldactone) is used for hypertension.

The nurse assesses the patient with chronic biventricular heart failure for paroxysmal nocturnal dyspnea (PND) by questioning the patient regarding a. the presence of restlessness and confusion. b. frequent awakening to void during the night. c. the presence of swelling in dependent body areas. d. waking in a panic with a feeling of suffocation.

d. Paroxysmal nocturnal dyspnea (PND) is awakening from sleep with a feeling of suffocation and a need to sit up to be able to breathe. Patients learn that sleeping with the upper body elevated on several pillows helps to prevent PND. Behavior changes are seen in late stages of HF. Nocturia occurs with HF as fluid moves back into the vascular system during recumbency, increasing renal blood flow. Dependent edema does not indicate PND.

The evaluation team for cardiac transplantation is evaluating patients. Which patient is most likely to receive the most benefit from a new heart? a. A 24-year-old man with Down syndrome who has received excellent care from parents in their 60s b. A 46-year-old single woman with a limited support system who has alcohol-induced cardiomyopathy c. A 60-year-old man with inoperable coronary artery disease who has not been compliant with lifestyle changes and rehabilitation programs d. A 52-year-old woman with end-stage coronary artery disease who has limited financial resources but is emotionally stable and has strong social support

d. The 52-yr-old woman does not have any contraindications for cardiac transplantation, even though she lacks the indication of adequate financial resources. The 24-yr-old man does not have a current cardiac diagnosis. The postoperative transplant regimen is complex and rigorous, and patients who have not been compliant with other treatments or who may not have the means to understand the care would not be good candidates. A history of drug or alcohol abuse is usually a contraindication to heart transplant.

A barrier to hospice referrals for patients with stage D heart failure is...? a. A family member refusal b. Scarcity of hospice facilities c. History of pacemaker placement d. Difficulty in estimating prognosis

d. Difficulty in estimating prognosis