Ch 25: Complication from Heart Disease prepU
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." Explanation: 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 is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home?
"I'm having trouble going up the steps during the day." Explanation: Difficulty with activities 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.
The nurse instructs a client with heart failure on restricting sodium in the diet. Which client statement indicates that teaching was effective?
"Lemon juice and herbs can be used to replace salt when cooking." Explanation: 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?
30% Explanation: 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.
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 Explanation: 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 Explanation: 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?
Administer the third sublingual nitroglycerin tablet. Explanation: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?
Arterial blood gases Explanation: 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 elevated blood urea nitrogen levels. Explanation:Elevated blood urea nitrogen indicates impaired renal perfusion in a client with left-sided heart failure. Serum sodium levels may be elevated. Reduced urine output or elevated blood potassium levels do not indicate impaired renal perfusion in a client with left-sided heart failure.
A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing action?
Assess oxygen saturation Explanation: The nurse's priority action is to assess oxygen saturation to determine the severity of the exacerbation. It is important to assess the oxygen saturation in a client with heart failure because below-normal oxygen saturation can be life-threatening. Treatment options vary according to the severity of the client's condition and may include supplemental oxygen, oral and IV medications, major lifestyle changes, implantation of cardiac devices, and surgical approaches. The overall goal of treatment of heart failure is to relieve symptoms and reduce the workload on the heart by reducing afterload and preload.
The nurse is developing a plan of care for a client following pericardiocentesis. Which interventions should the nurse implement? Choose all that apply.
Assess vital signs every 15 minutes for the first hour. Monitor heart and lung sounds. Record fluid output. Evaluate the cardiac rhythm. Explanation: The nurse should monitor the vital signs for any client who has undergone surgery. Because this procedure requires entering the pericardial sac, assessing heart and lung sounds assists in determining heart failure. The pericardial fluid is recorded as output and assessing the cardiac rhythm allows to assess for cardiac failure. The client should be kept in the semi-Fowler's position, not flat.
The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure?
Atrial fibrillation Explanation: 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 pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
BP and pulse measurements every 15 to 30 minutes Explanation: Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.
The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure?
Brain natriuretic peptide (BNP) Explanation: 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.
The nursing instructor is teaching their clinical group how to assess a client for congestive heart failure. How would the instructor teach the students to assess a client with congestive heart failure for nocturnal dyspnea?
By questioning how many pillows the client normally uses for sleep Explanation: The nurse should ask the client about nocturnal dyspnea by questioning how many pillows the client normally uses for sleep. This is because being awakened by breathlessness may prompt the client to use several pillows in bed. Collecting the client's urine output, observing the client's diet, or measuring the client's abdominal girth does not help assess for nocturnal dyspnea.
A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?
Call for a chest x-ray. Explanation: A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.
A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next?
Check the client's potassium level. Explanation: The client is asymptomatic but has had a change in heart rhythm. More information is needed before calling the health care provider. Because the client is taking furosemide, a potassium-wasting diuretic, the next action would be to check the client's potassium level. The nurse would then call the health care provider with a more complete database. The health care provider will need to be notified after the nurse checks the latest potassium level. The intake and output will not change the heart rhythm. Administering potassium requires a health care provider's order.
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) Explanation: 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 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 III (Moderate) Explanation: 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.
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
Dyspnea on exertion Explanation: 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.
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) Explanation: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.
Which is a cerebrovascular manifestation of heart failure?
Dizziness Explanation: Cerebrovascular manifestations of heart failure include dizziness, lightheadedness, confusion, restlessness, and anxiety. Tachycardia is a cardiovascular manifestation. Ascites is a gastrointestinal manifestation. Nocturia is a renal manifestation.
The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?
Dizziness Explanation: Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion include dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.
Which diagnostic study is usually performed to confirm the diagnosis of heart failure?
Echocardiogram Explanation: 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 heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump?
Echocardiogram Explanation: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm cor pulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart's conduction system.
The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?
Elevate the head of the bed. Explanation: 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.
The nurse is teaching a client about lifestyle modifications after a heart failure diagnosis. What will be included in the teaching?
Engage in exercise daily. Explanation: Lifestyle recommendations after heart failure include restriction of dietary sodium; avoidance of excessive fluid intake, excessive alcohol intake, and smoking; weight reduction when indicated; and regular exercise. The restriction of potassium is not required. Drinking 3 liters of fluid per day would be excessive for a client with heart failure.
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?
Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. Explanation: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?
Gradual unexplained weight gain Explanation: 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.
A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload?
Head of the bed elevated 45 degrees and lower arms supported by pillows Explanation: 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.
Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?
IV Explanation: 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?
Increased pulmonary artery diastolic pressure Explanation: 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 venous return. Explanation: 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?
JVD is noted 4 cm above the sternal angle. Explanation: 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 Explanation: 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?
Jugular venous distention Explanation: 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 Explanation: 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?
Lie very still at intermittent times during the test. Explanation: 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) Explanation: A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.
A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
Low serum potassium level Explanation: Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood pressure decreases, blood volume decreases, and urine output increases.
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?
Low-sodium diet Explanation: Medical management of both left-sided and right-sided heart failure is directed at reducing the heart's workload and improving cardiac output primarily through dietary modifications, drug therapy, and lifestyle changes. A low-sodium diet is prescribed, and fluids may be restricted. Because the client will be on a diuretic such as Lasix, he may become potassium depleted and would need potassium in the diet. A low-cholesterol and low-fat diet may be ordered but are not specific to the heart failure.
Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?
Monitor blood pressure frequently Explanation: Milrinone is a phosphodiesterase inhibitor that delays the release of calcium from intracellular reservoirs and prevents the uptake of extracellular calcium by the cells. This promotes vasodilation, resulting in decreased preload and afterload and reduced cardiac workload. Milrinone is administered intravenously to clients with severe HF, including those who are waiting for a heart transplant. Because the drug causes vasodilation, the client's blood pressure is monitored before administration because if the client is hypovolemic the blood pressure could drop quickly. The major side effects are hypotension and increased ventricular dysrhythmias. Blood pressure and the electrocardiogram (ECG) are monitored closely during and after infusions of milrinone.
A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)?
Myocardial ischemia Explanation: 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 client with cardiac failure is taught to report which symptom to the health care provider or clinic immediately?
Persistent cough Explanation:Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite, weight gain, interrupted sleep, unusual shortness of breath, and increased swelling should also be reported immediately.
The nurse is caring for a client with heart failure who has been prescribed digoxin. What laboratory value for the client can precipitate digoxin toxicity?
Potassium 3.0 milliequivalents per liter Explanation: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. A potassium level of potassium 3.0 milliequivalents per liter is low or hypokalemic. A potassium level of 5.6 is high or hyperkalemic. The sodium levels do not precipitate digoxin toxicity.
The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide?
Potassium level of 3.1 Explanation:Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These drugs increase sodium and therefore water excretion, but they also increase potassium excretion. If a client becomes hypokalemic, digitalis toxicity is more likely. The BNP does not demonstrate a severe heart failure. Sodium level of 135 is within normal range, as is the hemoglobin level.
Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?
Preload Explanation: 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 client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?
Pulmonary congestion Explanation: When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.
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.)
Pulmonary crackles Dyspnea Cough Explanation: 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.
A client has been diagnosed with heart failure. What is the major nursing outcome for the client?
Reduce the workload on the heart. Explanation: Specific objectives of medical management of heart failure include reducing the workload on the heart by reducing preload and afterload. The other choices are objectives that may be supportive of a healthy lifestyle, but are not specific to a client with heart failure.
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?
Respiratory alkalosis Explanation: 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 Explanation: Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).
A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure?
Right-sided heart failure Explanation: 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.
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 going into cardiogenic shock. Explanation: 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.
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?
The development of left-sided heart failure Explanation: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.
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 Explanation: 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?
The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels. Explanation: 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. Explanation: 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?
Titrate oxygen therapy. Explanation: 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?
Treat pulseless ventricular tachycardia. Explanation: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.
The student nurse is caring for a client with heart failure. Diuretics have been prescribed. What method might be used with a debilitated client to help the nurse evaluate the client's response to diuretics?
Using a urinary catheter Explanation: To evaluate response to diuretics, a urinary catheter is used. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. A biventricular pacemaker is used to sustain life.
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?
Ventricular assist device (VAD) Explanation: 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
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?
Weighing the client daily at the same time each day Explanation: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.
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?
Withhold the drug and inform the primary health care provider. Explanation: 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.
The client asked the nurse to describe Stage C heart failure. What is the best explanation by the nurse?
a client who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity Explanation: Once a patient has structural heart disease, the client has progressed from stage A to either stage B or stage C. The difference between B and C has to do with the presence of signs and symptoms of heart failure. When dyspnea and fatigue occur with exertion, heart failure Stage C is suspected. Stage D is a client with heart failure symptoms and maximal medical therapy.
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound?
a third heart sound (S3). Explanation: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 client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition?
acute pulmonary edema. Explanation:Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.
The nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will decrease preload?
administration of a vasodilating drug (as ordered by a health care provider) Explanation: 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 client has been diagnosed with congestive heart failure. This client's cardiac function has been compromised since the client suffered a myocardial infarction 3 years ago. Heart failure is classified by:
amount of activity restriction the failure imposes. Explanation: Chronic heart failure is classified based on the amount of activity restriction it imposes. Although organizations that develop the classifications may have varying stages, they are all based on the level of activity restriction.
The nurse is admitting a client with heart failure. What factor will worsen the client's myocardial function?
arterial pH 7.28 Explanation:Hypoxia, acidosis, renal failure, and electrolyte imbalance will decrease myocardial function for clients with heart failure. The pH of 7.28 is an acidosis. The BUN is normal at 22 mg/dL. The potassium of 3.9 mEq/L is within the normal range. A hemoglobin of 11.9 g/dL will not decrease myocardial function.
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?
ascites Explanation: 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?
ascites Explanation: 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 who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:
canned peas. Explanation: There is a wide variety of foods that the client can still eat; the key is to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. It is important to read food labels and look for foods that contain less than 300 mg sodium/serving.
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 Explanation: 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 admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema?
decreased left ventricular pumping Explanation: Pulmonary edema is an acute event that results from heart failure. Myocardial scarring, resulting from ischemia, limits the distensibility of the ventricle, making it vulnerable to demands for increased workload. When the demand on the heart increases, there is resistance to left ventricular filling and blood backs up into the pulmonary circulation. Pulmonary edema quickly develops.
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 Explanation: 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 Explanation: 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.
Frequently, what is the earliest symptom of left-sided heart failure?
dyspnea on exertion Explanation: Dyspnea on exertion is often the earliest symptom of left-sided 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 Explanation: 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?
heart rate of 55 beats per minute Explanation: 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 Explanation: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 is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion?
inadequate cardiac output Explanation: 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?
inadequate tissue perfusion Explanation: 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 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 Explanation: 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.
A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first?
mask Explanation: Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen is one of the first tools used to fight pulmonary edema. A mask, rather than nasal cannula, is needed to deliver the maximum percentages of oxygen. Intubation is reserved for when respiratory failure occurs. Mechanical ventilation is applied once respiratory failure occurs.
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?
nausea and vomiting Explanation: 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?
orthopnea Explanation: 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. Explanation: 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.
When the client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating
orthopnea. Explanation: 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?
peripheral edema Explanation: 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.
The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure?
pitting edema Explanation: The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response. Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a thickened left ventricle, seen with aortic stenosis or hypertension. The decreased oxygen saturation levels are from hypoxemia.
The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity?
potassium level of 2.8 mEq/L Explanation: Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.
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?
pulmonary crackles Explanation: 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.
A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of
pulmonary embolism. Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.
A nurse suspects that a client has digoxin toxicity. The nurse should assess for:
vision changes. Explanation: Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.
A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?
visual disturbances. Explanation: Digoxin toxicity may cause visual disturbances (e.g., flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (e.g., headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (e.g., abnormal heart rate, arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.
A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?
weight. Explanation: Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.
