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A client with left ventricular heart failure is taking digoxin 0.25 mg daily. What changes does the nurse expect to find if this medication is therapeutically effective? Select all that apply. 1 Diuresis 2 Tachycardia 3 Decreased edema 4 Decreased pulse rate 5 Reduced heart murmur 6 Jugular vein distention
1 Diuresis 2 Tachycardia 4 Decreased pulse rate Digoxin increases kidney perfusion, which results in urine formation and diuresis. The urine output increases because of improved cardiac output and kidney perfusion, resulting in a reduction in edema. Because of digoxin's inotropic and chronotropic effects, the heart rate will decrease. Digoxin increases the force of contractions (inotropic effect) and decreases the heart rate (chronotropic effect). Digoxin does not affect a heart murmur. Jugular vein distention is a specific sign of right ventricular heart failure; it is treated with diuretics to reduce the intravascular volume and venous pressure.
A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The healthcare provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. What nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition? 1 Perform daily weights 2 Auscultate breath sounds 3 Monitor intake and output 4 Assess for dependent edema
2 Auscultate breath sounds Maintaining adequate gas exchange and minimizing hypoxia with pulmonary edema are critical; therefore, assessing the effectiveness of furosemide therapy as it relates to the respiratory system is most important. Furosemide inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule, causing diuresis; as diuresis occurs fluid moves out of the vascular compartment, thereby reducing pulmonary edema and the bilateral crackles. Although a liter of fluid weighs approximately 2.2 pounds (1 kilogram) and weight loss will reflect the amount of fluid lost, it will take time before a change in weight can be measured. Although identifying a greater output versus intake indicates the effectiveness of furosemide, it is the client's pulmonary status that is most important with acute pulmonary edema. Although the lessening of a client's dependent edema reflects effectiveness of furosemide therapy, it is the client's improving pulmonary status that is most important.
A client with hypertensive heart disease, who had an acute episode of heart failure, is to be discharged on a regimen of metoprolol and digoxin. What outcome does the nurse anticipate when metoprolol is administered with digoxin? 1 Headaches 2 Bradycardia 3 Hypertension 4 Junctional tachycardia
2 Bradycardia Metoprolol and digoxin both exert a negative chronotropic effect, resulting in a decreased heart rate. Metoprolol reduces, not produces, headaches. These drugs may cause hypotension, not hypertension. These drugs may depress nodal conduction; therefore, junctional tachycardia would be less likely to occur.
A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply. 1 Collapsed neck veins 2 Distended abdomen 3 Dependent edema 4 Urinating at night 5 Cool extremities
2 Distended abdomen 3 Dependent edema 4 Urinating at night Right-sided heart failure is associated with increased systemic venous pressures and congestion, as manifested by a distended abdomen, dependent edema, and urinating at night. Distended, not collapsed, neck veins occur in right-sided heart failure. Cool extremities are key features of left-sided heart failure.
A nurse teaches the parents of an infant with a cardiac defect how to detect impending heart failure. What should the parents be taught to identify as an early sign? 1 Slowed respiration 2 Increased heart rate 3 Distended neck veins 4 Increased urine output
2 Increased heart rate Tachycardia results from sympathetic stimulation in the setting of heart failure; it is the body's attempt to increase cardiac output and increase oxygen supply to the body's cells. The respirations will increase, not decrease, when heart failure occurs. Distended neck veins occur only in adults when heart failure has progressed to systemic congestion. Urinary output is decreased as a result of sodium and water retention.
A nurse discovers lower extremity pitting edema in a client with right ventricular heart failure. Which information should the nurse consider when planning care? 1 Client has decreased plasma colloid osmotic pressure. 2 Client has increased tissue colloid osmotic pressure. 3 Client has increased plasma hydrostatic pressure. 4 Client has decreased tissue hydrostatic pressure.
3 Client has increased plasma hydrostatic pressure. In right ventricular heart failure, blood backs up in the systemic capillary beds; the increase in plasma hydrostatic pressure shifts fluid from the intravascular compartment to the interstitial spaces, causing edema. Increase in tissue (interstitial) colloid osmotic pressure occurs with crushing injuries or if proteins pathologically shift from the intravascular compartment to the interstitial spaces, pulling fluid and causing edema. In right ventricular heart failure, increased fluid pressure in the intravascular compartment causes fluid to shift to the tissues; the tissue hydrostatic pressure does not decrease. Although a decrease in colloid osmotic (oncotic) pressure can cause edema, it results from lack of protein intake, not increased hydrostatic pressure associated with right ventricular heart failure.
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? 1 "My ankles are swollen." 2 "I am tired at the end of the day." 3 "When I eat a large meal, I feel bloated." 4 "I have trouble breathing when I walk rapidly."
4 "I have trouble breathing when I walk rapidly." Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "I am tired at the end of the day" is not specific to left ventricular heart failure. The statement "When I eat a large meal, I feel bloated" is not specific to left ventricular heart failure.
A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question? 1 Reduces edema 2 Increases cardiac conduction 3 Increases rate of ventricular contractions 4 Slows and strengthens cardiac contractions
4 Slows and strengthens cardiac contractions Digoxin increases the strength of myocardial contractions (positive inotropic effect) and, by altering the electrophysiological properties of the heart, slows the heart rate (negative chronotropic effect). Digoxin increases the strength of the contractions but decreases the heart rate. Although a reduction in edema may result from the increased blood supply to the kidneys, it is not the reason for administering digoxin. Digoxin decreases, not increases, cardiac impulses through the conduction system of the heart.
A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? 1 Allows excess tissue fluid to be excreted 2 Helps to control the volume of food intake and thus weight 3 Aids the weakened heart muscle to contract and improves cardiac output 4 Assists in reducing potassium accumulation that occurs when sodium intake is high
1 Allows excess tissue fluid to be excreted A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.
Which nursing interventions may promote safe drug administration in a child diagnosed with heart failure who is receiving digoxin? Select all that apply. 1 Checking for compliance with the client's drug regimen 2 Monitoring the client's serum potassium and magnesium levels regularly 3 Administering digoxin only through the intramuscular route 4 Calculating the correct dosage form, prescribed amounts, and the prescriber's order 5 Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly
1 Checking for compliance with the client's drug regimen 2 Monitoring the client's serum potassium and magnesium levels regularly 4 Calculating the correct dosage form, prescribed amounts, and the prescriber's order 5 Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly\ Digoxin may alter the serum potassium and serum magnesium levels, which affects heart function. Calculating the correct dose according to the healthcare provider's orders helps to prevent drug toxicity. Checking for compliance with the client's drug regimen is important so that the child does not have drug to drug interactions. Monitoring and recording drug intake and output, heart rate, blood pressure, daily weight, and respiration rate is a part of general nursing care. Administering digoxin through the intramuscular route is not advised because this method is very painful.
The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience? 1 Dependent edema in the evening 2 Chest pain that decreases with rest 3 Palpitations in the chest when resting 4 Frequent coughing with yellow sputum
1 Dependent edema in the evening Decreased cardiac output causes fluid retention, which results in dependent edema; this is often noticed in the evening after the client has been standing or sitting for prolonged periods. Chest pain is indicative of cardiac ischemia. Palpitations are indicative of cardiac dysrhythmias. Coughing with yellow sputum is indicative of an infectious process in the respiratory tract; pink, frothy sputum is associated with pulmonary edema that can result from heart failure.
The parent of a 5-month-old infant with heart failure questions the necessity of weighing the baby every morning. What does the nurse say that this daily information is important in determining? 1 Fluid retention 2 Kidney function 3 Nutritional status 4 Medication dosage
1 Fluid retention Fluid retention is reflected by an excessive weight gain in a short period. Inadequate cardiac output decreases blood flow to the kidneys and thus leads to increased intracellular fluid and hypervolemia. Although this assessment may add information to the data regarding kidney function, other assessments, such as hourly urine output, blood urea nitrogen concentration, and creatinine level more significantly reflect kidney function. Weight gain resulting from nutritional intake is gradual and will not vary greatly on a day-to-day basis. Although weight is used to determine medication dosages, dosages do not need to be recalculated according to changes in daily weights.
A client with a history of heart failure and atrial fibrillation reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain? 1 Fluid retention 2 Urinary retention 3 Renal insufficiency 4 Abdominal distention
1 Fluid retention With the client's history and the large weight gain, fluid retention is the most likely cause of the increase in weight. Urinary retention occurs in the bladder, not the tissues, and does not account for the large weight gain. Renal insufficiency can occur with heart failure, but it is not the primary etiological factor of the sudden weight gain. Abdominal distention usually is caused by gas in the intestine and should not contribute to this large a weight gain. If the abdomen is enlarged, assessment by ballottement should be done to determine whether enlargement is caused by fluid in the peritoneal cavity (ascites).
A client with heart failure is receiving digoxin and hydrochlorothiazide. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply . 1 Nausea 2 Yellow vision 3 Irregular pulse 4 Increased urine output 5 Heart rate of 64 beats per minute
1 Nausea 2 Yellow vision 3 Irregular pulse Signs and symptoms of digoxin toxicity include bradycardia, headache, dizziness, confusion, nausea, and visual disturbances (blurred vision or yellow vision). In addition, ECG findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias, all causing an irregular pulse. Increased urine output is an expected effect of the diuretic furosemide; a pulse rate of 64 beats per minute is an acceptable rate when a client is receiving digoxin.
A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). Which goal is priority during the acute phase of recovery? 1 Promote pain relief 2 Increase activity tolerance 3 Prevent cardiac dysrhythmias 4 Maintain potassium and sodium intake
1 Promote pain relief The major goal is to manage pain. Pain relief helps increase the oxygen supply and decrease myocardial oxygen demand, decreasing the workload of the heart. Increasing activity tolerance is the primary focus during the rehabilitative phase after an MI, not during the acute phase. While preventing dysrhythmia is important, it is not the priority. Although maintaining potassium intake is important, sodium should be limited to minimize fluid retention, which increases the workload on the heart.
A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first? 1 Raise the client to high-Fowler position 2 Obtain the apical pulse and blood pressure 3 Call the primary healthcare provider immediately 4 Monitor the pulse oximeter to ascertain the oxygen level
1 Raise the client to high-Fowler position Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart. Obtaining a full set of vital signs would be the next priority after changing the client position. Calling the primary healthcare provider immediately would not be useful without having a full set of vital signs. The vital signs should include the oxygen saturation, which the healthcare provider would expect the nurse to provide.
A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify? 1 Support systems that can assist the client at home 2 Potential nursing homes in which the client can recuperate 3 Agencies that can help the client regain activities of daily living 4 Ways that the client can develop relationships with neighbors
1 Support systems that can assist the client at home The rehabilitative phase requires a balance between activity and rest; supportive individuals are needed to perform more strenuous household tasks and to provide emotional support. A client with mild heart failure does not need inpatient care. A support system should be identified before considering community agencies. More information is needed before encouraging the development of relationships with neighbors.
The primary healthcare provider has prescribed a stat chest x-ray exam and electrocardiogram for a client with a history of heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. Which immediate actions will the nurse take? Select all that apply. 1 Tell a staff member to get the electrocardiogram machine. 2 Notify the x-ray department that a chest x-ray exam must be done stat. 3 Have a staff member notify the nursing supervisor of the change in client status. 4 Notify the healthcare provider of the change in the oxygen saturation to ask what to do. 5 Tell the certified nursing assistant to get a prescription from the healthcare provider to increase the oxygen. 6 Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the healthcare provider.
1,2, 3, 6 1 Tell a staff member to get the electrocardiogram machine. 2 Notify the x-ray department that a chest x-ray exam must be done stat. 3 Have a staff member notify the nursing supervisor of the change in client status. 6 Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the healthcare provider. A staff member can get the electrocardiogram machine and start the procedure. Ancillary personnel are trained to do electrocardiograms even if they are not able to interpret the results. Anyone can notify the x-ray department that the chest x-ray exam must be done. It is important to delegate the tasks to a specific person. Increasing the oxygen without a prescription is appropriate in the short term, but the nurse must obtain a prescription when notifying the healthcare provider. Notifying the healthcare provider of the change in oxygen saturation is appropriate, but it would be expected that nursing judgment had taken place and the oxygen already was increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a prescription is an inappropriate action as a CNA is not allowed to take medical prescriptions. Taking a medical prescription is a nursing role.
When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? 1 Interview the client for a health history. 2 Assess the client's heart and lung sounds. 3 Monitor the client's pulse and temperature. 4 Obtain the client's blood specimen for electrolytes.
2 Assess the client's heart and lung sounds. With heart failure, the left ventricle is not functioning effectively, which is evidenced by an increased heart rate and crackles associated with pulmonary edema. The health history interview is done after vital signs and breath sounds are obtained and the client is stabilized. Although an infection would complicate heart failure, there are no signs that indicate this client has an infection. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.
A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? 1 The furosemide is causing dehydration. 2 Cloudy urine may be indicative of infection. 3 The client has inadequate hourly urine output. 4 All of the indications are within normal findings.
2 Cloudy urine may be indicative of infection. Cloudy urine may be indicative of infection, which is also a risk with Foley catheters. A urinalysis should be performed to confirm or rule out a urinary tract infection. The furosemide may cause dehydration, but other findings would have to be assessed, such as skin turgor. Hourly urine output should be at least 30 mL, which is being surpassed. Urine is expected to be clear amber colored; cloudy is not within expected normal appearance.
A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema should the nurse initially assess? 1 Proteinemia 2 Contractures 3 Tissue ischemia 4 Thrombus formation
3 Tissue ischemia Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia, and should be assessed first. Proteinemia and contractures are not complications resulting from long-term edema. Although thrombus formation may occur, the initial assessment is perfusion (tissue ischemia).
The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition? 1 Loss of cellular constituents in blood 2 Rapid osmosis from tissue spaces to cells 3 Increased pressure within the circulatory system 4 Rapid diffusion of solutes and solvents into plasma
3 Increased pressure within the circulatory system Failure of the right ventricle causes an increase in pressure in the systemic circulation. To equalize this pressure, fluid moves into the tissues, causing edema, and into the abdominal cavity, causing ascites; ascites leads to an increased abdominal girth. There is no loss of the cellular constituents in blood with right ventricular heart failure. Ascites is the accumulation of fluid in an extracellular space, not intracellular. The opposite of rapid diffusion of solutes and solvents into plasma results when there is a pressure increase in the systemic circulation.
While auscultating the heart, a healthcare provider notices S 3 heart sounds in four clients. Which client is at more risk for heart failure? 1 Child client 2 Pregnant client 3 Older adult client 4 Young adult client
3 Older adult client The S3 is the third heart sound heard after the normal "lub-dub." It is indicative of congestive heart failure in adults over 30 years old. In young, pregnant, and under 30 year old clients, the third heart sound is often considered to be a normal parameter.
A 4-month-old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition? 1 Decreased tremors 2 Increased hours of sleep 3 Weight loss during next 2 days 4 More rapid heart rate within 2 days
3 Weight loss during next 2 days Weight loss indicates fluid loss. Water retention is a classic sign of congestive heart failure. Tremors are not typical in infants with heart disease. Tremors are related to central nervous system irritability. If the infant's condition improved, energy would increase and sleeping needs would decrease. Tachycardia is a sign of congestive heart failure. The purpose of the cardiotonic is to slow the heart rate.
A nurse is caring for a client who has been admitted with right-sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8 mm depression after release. How should the edema be documented? 1 1+ 2 2+ 3 3+ 4 4+
4 4+ Dependent edema around the area of feet and ankles often indicates right-sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds, then releasing to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2+ indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.
