Hinkle CH 25 (HF)

Before discharge, which instruction should a nurse give to a client receiving digoxin? "Take an extra dose of digoxin if you miss one dose." "Call the physician if your heart rate is above 90 beats/minute." "Call the physician if your pulse drops below 80 beats/minute." "Take digoxin with meals."

"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.

The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding? "Can't walk without becoming short of breath" "Has paroxysmal nocturnal dyspnea when walking" "Has orthopnea when walking" "Experiences exertional dyspnea when walking 3 feet; states, I cannot catch my breath."

"Experiences exertional dyspnea when walking 3 feet; states, I cannot catch my breath." Exertional dyspnea is the effort at breathing when active. Answer A is vague and does not give a more detailed explanation for documentation purposes. Orthopnea is the inability to breathe unless sitting upright, and paroxysmal nocturnal dyspnea is being awakened by breathlessness.

The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home? "I eat six small meals a day when I am hungry." "My food tastes bland without salt." "I cut back on going up the steps during the day." "My best time of the day is the morning."

"I cut back on going up the steps during the day." Cutting back on activity like climbing stairs is an indication of a lessened ability to exercise. Eating small meals and not using salt are usually indicated for clients with heart failure. The client's assertion about morning being the best time of day is a vague statement.

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." "My feet are bigger than normal." "My pants don't fit around my waist." "I don't have the same appetite I used to."

"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 instructs a client with heart failure on restricting sodium in the diet. Which client statement indicates that teaching was effective? "I will add a water softener to my water at home." "Food prepared at home is saltless unless I add it while cooking." "Lemon juice and herbs can be used to replace salt when cooking." "Canned vegetables have low sodium content."

"Lemon juice and herbs can be used to replace salt when cooking." For the client on a low-sodium or sodium-restricted diet, a variety of flavorings, such as lemon juice, vinegar, and herbs, may be used to improve the taste of the food and facilitate acceptance of the diet. Sodium is contained in municipal water. Water softeners also increase the sodium content of drinking water. Although the major source of sodium in the average American diet is salt, many types of natural foods contain varying amounts of sodium. Even if no salt is added in cooking and if salty foods are avoided, the daily diet will still contain about 2000 mg of sodium. Fresh fruits and vegetables are low in sodium and should be encouraged.

A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be? 5% 30% 55% 65%

30% The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure. The normal EF is 55%-65%. An EF of 5% is not life sustaining and an EF of 30% is about half the normal percentage.

A nurse is caring for a client with a cardiac disorder who is prescribed diuretics. What important factor should the nurse include in this client's teaching plan? A discussion of the signs and symptoms of anemia. A discussion of the signs and symptoms of electrolyte and water loss. A discussion of the required room temperature conditions in the home environment. A discussion on how to avoid direct sunlight when outdoors.

A discussion of the signs and symptoms of electrolyte and water loss. Instructions for clients taking diuretics should include a discussion of the signs and symptoms of electrolyte and water loss and the importance of adhering to the prescribed medication schedule. The client need not be informed about the symptoms of anemia or be advised to maintain any particular room temperature or avoid sunlight; use of diuretics does not increase risk for developing photosensitivity or anemia.

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 Calcium channel blocker Diuretic Bile acid sequestrants

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 (ICSI, 2011).

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 clients reports that these symptoms came on suddenly. The nurse knows that these are symptoms of what condition? Acute pulmonary edema Progressive heart failure Pulmonary hypertension Cardiogenic shock

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 administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg? Hold any further treatment until the client's blood pressure increases. Notify the health care provider of the chest pain. Administer the third sublingual nitroglycerin tablet. Wait ten minutes after the second tablet to assess pain.

Administer the third sublingual nitroglycerin tablet. The nurse will need to administer the third sublingual nitroglycerin tablet. Nitroglycerin is given as three doses for chest pain as the client's blood pressure can tolerate it. The health care provider will be notified after three tablets. The nurse should not hold any further treatment if the client has chest pain. The dosing of nitroglycerin is a five-minute wait.

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? Pulse oximetry Listening to breath sounds End-tidal CO2 Arterial blood gases

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 reduced urine output. Assess for reduced blood sodium levels. Assess for elevated blood potassium levels. Assess for elevated blood urea nitrogen levels.

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.

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure? Atrial fibrillation First-degree heart block Supraventricular tachycardia Sinus tachycardia

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.

A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring? Heart rate of 72 beats/minute Respiratory rate of 20 breaths/minute Blood pressure 80/46 mm Hg Oxygen saturation 94%

Blood pressure 80/46 mm Hg The body can compensate for changes in heart function that occur over time. When cardiac output falls, the body uses certain compensatory mechanisms designed to increase stroke volume and maintain blood pressure. These compensatory mechanisms can temporarily improve the client's cardiac output but ultimately fail when contractility is further compromised. A heart rate of 72 beats/minute is within normal range as well as the respiratory rate and oxygen saturation.

Which is a key diagnostic indicator of heart failure? Blood urea nitrogen (BUN) Creatinine Brain natriuretic peptide (BNP) Complete blood count (CBC)

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.

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? Blood urea nitrogen (BUN) Creatinine Brain natriuretic peptide (BNP) Complete blood count (CBC)

Brain natriuretic peptide (BNP) BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.

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 II (Mild) Class III (Moderate) Class IV (Severe)

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 assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? Tachycardia Ascites Nocturia Dizziness

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.

The nurse is caring for a client in the hospital with chronic heart failure who 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, the client becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)? Class I (Mild) Class II (Mild) Class III (Moderate) Class IV (Severe)

Class III (Moderate) This client is comfortable at rest, but has "marked limitations" on physical activity. Merely walking down the hall causes fatigue and dyspnea. Therefore, this client is in Class III (moderate). With Class I (mild), ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea, and the client does not experience any limitation of activity. With Class II (mild), the client is comfortable at rest, but the ordinary physical activity of daily living results in fatigue, heart palpitations, or dyspnea; the client's activity is only slightly limited. With Class IV (severe), symptoms of cardiac insufficiency occur at rest, and discomfort increases if any physical activity is undertaken.

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) Increase in CVP Decrease in blood pressure Absence of cough

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.

A client is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client? Digoxin immune FAB Ibuprofen Warfarin Amlodipine

Digoxin immune FAB Digibind binds with digoxin and makes it unavailable for use. The digibind dosage is based on the digoxin level and the patient's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.

The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? Decreased urinary output Dyspnea on exertion Hypotension Tachycardia

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.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Electrocardiogram (ECG) Echocardiogram Serum electrolytes Blood urea nitrogen (BUN)

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 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. Assess pulse oximetry reading. Report a decrease in urine output. Notify the family of a change in condition.

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. Reporting a decrease urine output is not a priority for the client. Notification of the family is not a priority to help with breathing.

A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence? The pericardial space is eliminated with scar tissue and thickened pericardium. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.

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).

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? Increased urine output Gradual unexplained weight gain Increased perspiration Sleeping in a chair or recliner

Gradual unexplained weight gain Clients with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention. Left-sided heart failure produces paroxysmal nocturnal dyspnea, which may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Right-sided heart failure does not cause increased perspiration or increased urine output.

The nurse is performing an initial assessment of a client diagnosed with heart failure (HF) that includes the client's sensorium and level of consciousness (LOC). Why is the assessment of the client's sensorium and LOC important in clients with HF? HF ultimately affects oxygen transportation to the brain. Clients with HF are susceptible to overstimulation of the sympathetic nervous system. Decreased LOC causes an exacerbation of the signs and symptoms of HF. The most significant adverse effect of medications used for HF treatment is altered LOC.

HF ultimately affects oxygen transportation to the brain. As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in clients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular (CV).

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 30 degrees and legs elevated on pillows Head of the bed elevated 45 degrees and lower arms supported by pillows Supine with arms elevated on pillows above the level of the heart Prone with legs elevated on pillows

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 client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure? Hypertension causes the heart's chambers to enlarge and weaken. Hypertension causes the heart's chambers to shrink. Heart failure occurs when blood pressures drops. Hypertension in older males regularly leads to heart failure.

Hypertension causes the heart's chambers to enlarge and weaken. Hypertension causes the heart's chambers to enlarge and weaken, making it impossible for the ventricles to eject all the blood they receive.

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

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

IV Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In class II, ADLs are slightly limited. In class III, ADLs are markedly limited.

Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure? Decreased central venous pressure Increase in the cardiac index Increased pulmonary artery diastolic pressure Decreased mean pulmonary artery pressure

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 pathophysiology of pericardial effusion is associated with all of the following except: Increased right and left ventricular end-diastolic pressures. Atrial compression. Increased venous return. Inability of the ventricles to fill adequately.

Increased venous return. Venous return is decreased (not increased) with Pericardial effusion because there is an increase in the pericardial fluid, which raises the pressure within the pericardial sac and compresses the heart. Increased right and left ventricular end-diastolic pressures, inability of the ventricles to fill adequately, and atrial compression are all effects of pericardial effusion.

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? No JVD is present. JVD is noted at the level of the sternal angle. JVD is noted 2 cm above the sternal angle. JVD is noted 4 cm above the sternal angle.

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 Dyspnea Pulmonary crackles Cough

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.

A new client has been admitted with right-sided heart failure. When assessing this client, the nurse knows to look for which finding? Pulmonary congestion Cough Dyspnea Jugular venous distention

Jugular venous distention When the right ventricle cannot effectively pump blood from the ventricle into the pulmonary artery, the blood backs up into the venous system and causes jugular venous distention and congestion in the peripheral tissues and viscera. All the other choices are symptoms 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 Right ventricular function Left atrial function Right atrial function

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.

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? Avoid any activity at least 2 hours before the test. Drink plenty of fluids during the test. Avoid dairy products a day before and a day after the test. Lie very still at intermittent times during the test.

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 feature is the hallmark of systolic heart failure? Low ejection fraction (EF) Pulmonary congestion Limited activities of daily living (ADLs) Basilar crackles

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 is the hallmark of heart failure? Low ejection fraction (EF) Pulmonary congestion Limited ADLs Basilar crackles

Low ejection fraction (EF) Although a low EF is a hallmark of heart failure (HF), the severity of HF is frequently classified according to the client's symptoms. Pulmonary congestion, limitation of ADLs, and basilar crackles are all symptoms of HF.

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)? Ineffective right ventricular contraction Myocardial ischemia Pulmonary embolus Cystic fibrosis

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 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 metoprolol captopril enalapril

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. Frequently this medication is titrated in a critical care unit for client safety. It is a preload and afterload reducer. Metoprolol is a beta-blocker. Captopril and enalapril are angiotensin-converting enzyme (ACE) inhibitors.

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole? Afterload Preload Ejection fraction Stroke volume

Preload Preload is 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.

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.) Jugular vein distention Ascites Pulmonary crackles Dyspnea Cough

Pulmonary crackles Dyspnea 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.

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? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

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.

The nurse recognizes which symptom as a classic sign of cardiogenic shock? Restlessness and confusion Hyperactive bowel sounds High blood pressure Increased urinary output

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? Left-sided heart failure Chronic heart failure Acute heart failure Right-sided heart failure

Right-sided heart failure Signs and symptoms of Right Ventricular Failure include: Weakness; Ascites; Weight gain; Nausea, vomiting; Dysrhythmias; Elevated central venous pressure; Jugular vein distention. The scenario does not indicate whether the heart failure is chronic or acute. Therefore, options A, B, and C are incorrect.

Which is a manifestation of right-sided heart failure? Accumulation of blood in the lungs Systemic venous congestion Increase in forward flow Paroxysmal nocturnal dyspnea

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. Some clients with left-sided heart failure get episodes of dyspnea at night, known as paroxysmal nocturnal dyspnea.

Assessment of a client on a medical surgical unit finds a regular heart rate of 120 beats per 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. What is the reason the nurse anticipates transferring the client to the intensive care unit? The client is experiencing heart failure. The client is going into cardiogenic shock. The client shows signs of aneurysm rupture. The client is in the early stage of right-sided heart failure.

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.

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 Duration of symptoms There is a marked limitation of physical activity. The client is unable to carry out any physical activity.

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 is administering furosemide to a client with heart failure. What best describes the therapeutic action of the medication? Furosemide blocks reabsorption of potassium on the collecting tubule. Furosemide promotes sodium secretion into the distal tubule. The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels. The medication promotes potassium secretion into the distal tubule and constrict renal vessels.

The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels. Loop diuretics such as furosemide blocks sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. Furosemide 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.

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. There is excess fluid volume in the venous system of the lower extremities. There is excess fluid volume in the arterial system of the lower extremities. There is excess fluid volume in the hepatic system.

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.

A client with a history of heart failure is returning from the operating room after inguinal hernia repair and the nurse assesses a low pulse oximetry reading. What is the most important nursing intervention? Assess for jugular vein distention. Administer pain medication. Titrate oxygen therapy. Assess the surgical incisional area.

Titrate oxygen therapy. The nurse needs to titrate oxygen therapy to increase the client's oxygen levels. Assessing for jugular vein distention and examining the surgical incision area will not meet the oxygen demands. Administering pain medication will not increase oxygenation levels.

The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts? Correct metabolic acidosis. Treat pulseless ventricular tachycardia. Prevent the development of hypotension. Reduce the development of torsade de pointes.

Treat pulseless ventricular tachycardia. During CPR, the medications provided will depend upon the client's condition and response to therapy. Amiodarone is used to treat pulseless ventricular tachycardia. Sodium bicarbonate is used to correct metabolic acidosis. Norepinephrine and dopamine are used to prevent the development of hypotension. Magnesium sulfate is used for the client with torsade de pointes.

A client taking an ACE inhibitor has developed a dry, hacking cough. Because of this side effect, the client no longer wants to take that medication. What medication that has similar hemodynamic effects does the nurse anticipate the health care provider ordering? Valsartan Furosemide Metoprolol Isosorbide dinitrate

Valsartan If the patient cannot continue taking an angiotensin-converting enzyme (ACE) inhibitor because of development of cough, an elevated creatinine level, or hyperkalemia, an angiotensin receptor blocker (ARB) or a combination of hydralazine and isosorbide dinitrate is prescribed (see Table 29-3).

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? Digoxin (Lanoxin) Valsartan (Diovan) Metolazone (Zaroxolyn) Carvedilol (Coreg)

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? Implanted cardioverter-defibrillator (ICD) Pacemaker Intra-aortic balloon pump (IABP) Ventricular assist device (VAD)

Ventricular assist device (VAD) VADs may be used for one of three purposes:(1) a bridge to recovery, (2) a bridge to transplant, or (2) 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

Which nursing intervention should the nurse perform when a client with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta-blockers? Observe for symptoms of pulmonary edema. Continue the drug and document in the client's chart. Withhold the drug and inform the primary health care provider. Check for signs of toxicity.

Withhold the drug and inform the primary health care provider. Before administering a beta-blocker, the nurse should monitor the client'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.

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 first heart sound (S1). a third heart sound (S3). a fourth heart sound (S4). a murmur.

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. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.

A nurse is assessing a client with heart failure. What breath sound is commonly auscultated in clients with heart failure? tracheal. fine crackles. coarse crackles. friction rubs.

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 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? call for respiratory therapy to intubate the client. administer oxygen, morphine, and a bronchodilator for client comfort. ask the client's family to consent to ventilator placement. administer oxygen and hope the client will reconsider.

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.

The nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will decrease preload? application of antiembolic stockings increasing activity administration of a vasodilating drug (as ordered by a health care provider) sustained elevation of the client's legs

administration of a vasodilating drug (as ordered by a health care provider) 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 (antiembolic stockings) or preventing blood from pooling in the extremities will increase preload.

A nurse is discussing cardiac hemodynamics with a client and explains the concept of afterload. What are other preexisting medical conditions to discuss that may increase afterload? Select all that apply aging hypertension mitral valve stenosis aortic valve stenosis diabetes mellitus

aging hypertension 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 valvular opening, resistance or afterload increases. Aging causes muscle stiffness, thus increasing afterload. Diabetes mellitus and mitral valve stenosis do not directly affect afterload.

The nurse is assessing a client with left-sided heart failure. What assessment finding is expected? ascites jugular vein distention air hunger pitting edema of the legs

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.

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure? warm extremities ascites resting bradycardia weight loss

ascites Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, ascites, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough. Mixed heart failures can have all symptoms of right and left plus cool extremities, resting tachycardia, and weight gain.

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided heart failure? warm extremities ascites resting bradycardia weight loss

ascites Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, ascites, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough. Mixed heart failures can have all symptoms of right and left plus cool extremities, resting tachycardia, and weight gain.

A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)? decrease in renal perfusion increased blood volume ejected from ventricle vasodilation of skin dehydration

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.

The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy? decreased left ventricular workload decreased right ventricular workload decreased peripheral perfusion to the extremities decreased renal perfusion

decreased left ventricular workload The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The therapeutic effect is decreased left ventricular workload. The IABP does not change right ventricular workload. The IABP increases perfusion to the coronary and peripheral arteries. The renal perfusion is not affected by IABP.

The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs? dopamine enalapril furosemide metoprolol

dopamine 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.

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 electrocardiogram cardiac catheterization cardiac ultrasound

echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan, not an electrocardiogram or cardiac ultrasound. Cardiac catheterization is not the diagnostic tool for this measurement.

A client has been diagnosed with right-sided heart failure based on symptomology. The cardiologist will confirm this suspicion through diagnostics. Which diagnostic(s) should the nurse anticipate in the client's plan of care? Select all that apply. electrocardiogram chest radiograph echocardiography cardiomyoplasty cardiac resynchronization

electrocardiogram chest radiograph echocardiography An echocardiogram is usually performed to confirm the diagnosis of heart failure, identify the underlying cause, and determine the ejection fraction (EF), which helps identify the type and severity of heart failure. This information may also be obtained noninvasively by radionuclide ventriculography or invasively by ventriculography as part of a cardiac catheterization procedure. A chest x-ray and an electrocardiogram (ECG) are obtained to assist in the diagnosis. Pulmonary arteriography does not apply. Cardiac resynchronization and cardiomyoplasty are not diagnostic procedures but interventions used to treat advanced heart failure.

The nurse is interviewing a client during an initial visit at a cardiologist's office. What symptom will the nurse expect to find as an early symptom of chronic heart failure? fatigue pedal edema nocturia irregular pulse

fatigue Fatigue is commonly the earliest symptom of chronic heart failure; it is caused by decreased cardiac output and tissue oxygenation. Pedal edema and nocturia are symptoms of heart failure, but they occur later in the course of the condition. An irregular pulse can be a complication of heart failure, but it is not necessarily an early indication of the condition.

A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber? blood pressure of 125/80 urine output of 300 mL in eight hours atrial fibrillation rhythm heart rate of 55 beats per minute

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. Blood pressure of 125/80 is normal. Urine output of 300 mL is adequate, so the kidneys are functioning. Atrial fibrillation is not a parameter to hold medication.

The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed? heart transplant ventricular access device implantable cardiac defibrillator (ICD) cardiac resynchronization therapy

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 monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options. Due to the client's high risk for developing __________ as a result of the prescribed medication, the nurse focuses on monitoring the client for ___________

hypokalemia, ventricular arrhythmia Furosemide, a loop diurectic, is often prescribed for clients who experience fluid volume overload due to a diagnosis of heart failure (HF). The client who is newly prescribed furosemide for the treatment of hypervolemia due to HF is at a high risk for developing fluid and electrolyte abnormalites, with a high risk for hypokalemia. Hypokalemia is a potentially life-threatening complication of loop diuretic therapy due to the risk for cardiac arrhythmias. When assessing a client for hypokalemia, the nurse monitors the client for ventricular arrhythmias. This is a priority in the provision of care for a client who is prescribed furosemide for the treatment of heart failure. Although hyponatremia and hyperuricemia are both potential side effects associated with diuretic therapy, they are not high risks for the client who is prescribed furosemide. Although a symptom of hyponatremia is nausea and joint pain is a symptom of hyperuremia, these are not findings that are expected for a client who experiences hypokalemia due to furosemide therapy.

The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion? ascites hepatomegaly inadequate cardiac output nocturia

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. Ascites is fluid in the abdomen, not a cause of congestion. Hepatomegaly is an enlarged liver, which does not cause crackling breath sounds. Nocturia, or voiding at night, does not cause crackling breath sounds.

The critical care nurse is caring for a client with cardiogenic shock. What is the premise for inserting an intra-aortic balloon pump? coronary artery stenosis inadequate tissue perfusion myocardial ischemia right atrial flutter

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. A myocardial infarction may lead to cardiogenic shock, but is not the premise for the intra-aortic balloon pump. Coronary artery stenosis is not related to shock. Right arterial flutter is not indicative of shock.

The nurse is receiving a client from the emergency in cardiogenic shock. What mechanical device does the nurse anticipate will be inserted into the client? cardiac pacemaker hypothermia-hyperthermia machine defibrillator intra-aortic balloon pump

intra-aortic balloon pump Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. The intra-aortic balloon pump increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client 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.

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival? lisinopril diltiazem bumetanide cholestyramine

lisinopril Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, beta-blockers, and diuretics such as bumetanide. 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. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.

The nurse is caring for a client with heart failure who is receiving a diuretic medication. What implementation will help the nurse evaluate the client's response of the medication? using mechanical ventilation measuring intake and output obtaining cardiac output with a pulmonary catheter asking the client about comfort level

measuring intake and output To evaluate response to a diuretic, intake and output are monitored. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. Asking the client about comfort level will not assess urinary output.

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 drowsiness, numbness increased cardiac output hypertension

moist, gurgling respirations Clients with acute pulmonary edema experience sudden dyspnea, wheezing, orthopnea, cough, cyanosis, and tachycardia. Respirations sound moist or gurgling. Drowsiness and numbness are not considered issues. Increased cardiac output is not part of this checklist. Hypertension is not an immediate symptom.

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client? Vasculitis nausea and vomiting Flexion contractures Enlargement of joints

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 nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis? increased appetite bibasilar rales cleared with coughing orthopnea resting bradycardia

orthopnea Decreased left ventricular function would be characterized by orthopnea, dyspnea, anorexia, bibasilar rales not cleared with coughing, and resting tachycardia.

When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating orthopnea. dyspnea upon exertion. hyperpnea. paroxysmal nocturnal dyspnea.

orthopnea. Clients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler position. Dyspnea upon exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective? skin rash peripheral edema bradycardia postural hypotension

peripheral edema Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective. The individual will also most like experience trachycardia instead of bradycardia if the heart failure is worsening ang not responding to captopril.

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? hypertension high urine output dry mucous membranes pulmonary crackles

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.