Ch 29

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? a) Left atrial function b) Left ventricular function c) Right atrial function d) Right ventricular 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.

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? a) Bilateral crackles b) Leg edema c) Productive cough d) Cyanosis of the lips

Leg edema Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough.

Which of the following is the hallmark of systolic heart failure? a) Basilar crackles b) Limitation of activities of daily living (ADLs) c) Low ejection fraction (EF) d) Pulmonary congestion

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 patient's symptoms.

When the nurse observes that the patient has increased difficulty breathing when lying flat, the nurse records that the patient is demonstrating which of the following? a) Hyperpnea b) Dyspnea on exertion c) Orthopnea d) Paroxysmal nocturnal dyspnea

Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler's position. Dyspnea on 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 admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which of the following assessment findings for this client? a) Jugular venous distention b) Nausea c) Pulmonary congestion d) Pedal edema

Pulmonary congestion When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.

Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)? a) Chlorothiazide (Diuril) b) Ethacrynic acid (Edecrin) c) Spironolactone (Aldactone) d) Bumetanide (Bumex)

Spironolactone (Aldactone) Aldactone is a potassium-sparing diuretic. A thiazide diuretic is Diuril. Bumex and Edecrin are loop diuretics.

A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals: a) peripheral edema. b) skin rash. c) dry cough. d) postural hypotension.

peripheral edema. Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure? a) Complete blood count (CBC) b) B-type natriuretic peptide (BNP) c) Serum electrolytes d) Blood urea nitrogen (BUN)

B-type natriuretic peptide (BNP) The BNP level is a key diagnostic indicator of HF; high levels are a sign of high cardiac filling pressure and can aid in both the diagnosis and management of HF (Institute for Clinical Systems Improvement [ICSI], 2011).

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? a) Echocardiogram b) A pulmonary arteriography c) A chest radiograph d) Electrocardiogram

Echocardiogram The heart?'s ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography is used to confirm corpulmonale. A chest radiograph can reveal the enlargement of the heart. An electrocardiogram is used to determine the activity of the heart?s conduction system.

Which of the following medications is a human brain natriuretic peptide (BNP) preparation? a) Captopril b) Enalapril c) Natrecor d) Metoprolol

Natrecor Nesiritide (Natrecor) is a preparation of human BNP that mimics the action of endogenous BNP, causing dieresis and vasodilation, reducing blood pressure, and improving cardiac output. It is a preload and afterload reducer. Metoprolol is a beta-blocker. Captopril and enalapril are angiotensin-converting enzyme (ACE) inhibitors.

When assessing a client with left-sided heart failure, the nurse expects to note: a) ascites. b) air hunger. c) pitting edema of the legs. d) jugular vein distention.

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.

On assessment, the nurse knows that a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity would have heart failure classified as Stage: a) A b) B c) D d) C

C Once a patient has structural heart disease, he 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 is suspected.

The nurse recognizes which of the following symptoms as a classic sign of cardiogenic shock? a) Restlessness and confusion b) Hyperactive bowel sounds c) High blood pressure d) 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 nurse suspects that a client has digoxin toxicity. The nurse should assess for: a) decreased urine output. b) hearing loss. c) vision changes. d) gait instability.

vision changes. 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 nurse taking care of a patient recently admitted to the ICU observes the patient coughing up large amounts of pink, frothy sputum. Auscultation of the lungs reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this patient is developing which of the following problems? a) Tuberculosis b) Bilateral pneumonia c) Acute exacerbation of chronic obstructive pulmonary disease d) Decompensated heart failure with pulmonary edema

Decompensated heart failure with pulmonary edema Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated HF with pulmonary edema.

Which of the following body system responses correlates with systolic heart failure (HF)? a) Increased blood volume ejected from ventricle b) Decrease in renal perfusion c) Dehydration d) Vasodilation of skin

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.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? a) BUN b) Echocardiogram c) Serum electrolytes d) Electrocardiogram (ECG)

Echocardiogram An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed in the initial workup.

The nurse is preparing to administer hydralazine and isosorbide dinitrate (Dilatrate). When obtaining vital signs, the nurse notes that the blood pressure is 90/60. What is the priority action by the nurse? a) Hold the medication and call the physician. b) Administer the hydralazine and hold the dinitrate. c) Administer a saline bolus of 250 mL and then administer the medication. d) Administer the medication and check the blood pressure in 30 minutes.

Hold the medication and call the physician. A combination of hydralazine and isosorbide dinitrate may be another alternative for patients who cannot take ACE inhibitors (ICSI, 2011). Nitrates (e.g., isosorbide dinitrate) cause venous dilation, which reduces the amount of blood return to the heart and lowers preload. Hydralazine lowers systemic vascular resistance and left ventricular afterload. If these medications lead to severe hypotension, the nurse should hold the medication and call the physician.

A 73-year-old client has been admitted to the cardiac step-down unit where you practice nursing. After diagnostics, she was brought to your unit with acute pulmonary edema. Which of the following symptoms would you expect to find during your assessment? a) Drowsiness, numbness b) Hypertensive c) Moist, gurgling respirations d) Increased cardiac output

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.

You are working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for you to closely monitor an older adult receiving digitalis preparations for cardiac disorders? a) Older adults are at increased risk for cardiac arrests. b) Older adults are at increased risk for asthma. c) Older adults are at increased risk for toxicity. d) Older adults are at increased risk for hyperthyroidism.

Older adults are at increased risk for toxicity. Older adults receiving digitalis preparations are at increased risk for toxicity because of the decreased ability of the kidneys to excrete the drug due to age-related changes. The margin between a therapeutic and toxic effect of digitalis preparations is narrow. Using digitalis preparations does not increase the risk of cardiac arrests, hyperthyroidism, or asthma.

The nurse is preparing to administer furosemide (Lasix) to a client with severe heart failure. What lab study should be of most concern for this client while taking Lasix? a) BNP of 100 b) Hemoglobin of 12 c) Potassium level of 3.1 d) Sodium level of 135

Potassium level of 3.1 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.

A physician orders digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? a) Sodium level of 152 mEq/L b) Magnesium level of 2.5 mg/dl c) Potassium level of 2.8 mEq/L d) Calcium level of 7.5 mg/dl

Potassium level of 2.8 mEq/L 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 right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema? a) The client says that he has been urinating less frequently at night. b) The client says he has been hungry in the evening. c) The client says he is short of breath when ambulating. d) The client says his rings have become tight and are difficult to remove.

The client says his rings have become tight and are difficult to remove. Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.

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? a) Digoxin (Lanoxin) b) Carvedilol (Coreg) c) Metolazone (Zaroxolyn) d) Valsartan (Diovan)

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 with left-sided heart failure complains of 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: a) acute pulmonary edema. b) right-sided heart failure. c) cardiogenic shock. d) pneumonia.

acute pulmonary edema. 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.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement? a) "I sleep on three pillows each night." b) "I don't have the same appetite I used to." c) "My pants don't fit around my waist." d) "My feet are bigger than normal."

"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.

Eighty six-year-old Susan Matthews has been rushed to the ED with pulmonary edema during your shift. She is going to need oxygen immediately. Which oxygen delivery system do you use first? a) Mechanical ventilation b) Intubation c) A mask d) A nasal cannula

A mask 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, in which case 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 patient arrives at the ED with an exacerbation of left-sided heart failure and complains of shortness of breath. Which of the following is the priority nursing intervention? a) Administer angiotensin-converting enzyme inhibitors b) Administer diuretics c) Assess oxygen saturation level d) Administer angiotensin II receptor blockers

Assess oxygen saturation level Assessment is priority to determine severity of the exacerbation. It is important to assess the oxygen saturation level of a heart failure patient, as below normal oxygen saturation level can be life-threatening. Treatment options vary according to the severity of the patient'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 patient symptoms and reduce the workload on the heart by reducing afterload and preload.

The Cardiac Nurse Clinician is teaching a group of clients with heart failure about self-management of their disease. What dietary advice should the Nurse Clinician give to clients with severe heart failure until edema resolves? a) Encourage increased intake of red meat. b) Avoid the intake of canned fruit and fruit juices. c) Avoid the intake of processed and commercially prepared foods. d) Encourage increased intake of vegetables with natural sodium.

Avoid the intake of processed and commercially prepared foods. Until edema resolves, a client with severe heart failure requires restriction of sodium to 500 to 1,000 mg/day. Therefore, processed and commercially prepared foods are eliminated. Vegetables with natural sodium, for example, beets, carrots, and "greens," should be avoided. Fresh, frozen, and canned fruit and fruit juices are not restricted. Increased intake of red meat should not be encouraged; it should be restricted to 6 oz per day.

A physician in the outpatient department examines a client with chronic heart failure to investigate recent-onset peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema? a) Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours b) Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours c) A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling d) A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling

Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours Pitting edema is documented as a +1 when a depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? a) Bibasilar crackles b) Right upper quadrant pain c) Dependent edema d) Jugular vein distention

Bibasilar crackles Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

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? a) Attach a pulse oximeter probe and obtain values. b) Observe for mist in the endotracheal tube. c) Call for a chest x-ray. d) Listen for breath sounds over the epigastrium.

Call for a chest x-ray. A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.

A client 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? a) Class II (Mild) b) Class III (Moderate) c) Class I (Mild) d) 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.

A patient with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, bradycardia, and muffled heart sounds. The senior nursing student recognizes these symptoms occur when a) Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. b) Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction. c) The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. d) The pericardial space is eliminated with scar tissue and thickened pericardium.

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 (eg, compression of the heart).

Which of the following is the primary cause of pulmonary or peripheral congestion? a) Nocturia b) Inadequate cardiac output c) Ascites d) Hepatomegaly

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.

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? a) Low-sodium diet b) Low-cholesterol diet c) Low-potassium diet d) Low-fat diet

Low-sodium diet 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.

A client diagnosed with heart failure presents with the following assessment data: temperature 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; pulse oximeter reading of 89%. Following the completion of your assessment, you prioritize your findings. Which findings indicate a need for immediate attention? a) Blood pressure b) Lung congestion c) Nausea d) Temperature

Lung congestion Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen or mechanical ventilation is used to support breathing. Inotropic medications, which improve myocardial contractility, are administered to relieve symptoms. It is lung congestion that needs to be relieved as quickly as possible, because pulmonary edema can be fatal. Supplemental oxygen or mechanical ventilation is used to support breathing. Inotropic medications, which improve myocardial contractility, are administered to relieve symptoms.

A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth daily, and furosemide (Lasix), 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause: a) nocturia and sleep disturbances. b) taste and smell alterations. c) dry mouth and urine retention. d) visual disturbances.

visual disturbances. Digoxin toxicity may cause visual disturbances (such as, flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (such as headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (abnormal heart rate and 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. The best indicator for the nurse to monitor is: a) weight. b) fluid intake and output. c) vital signs. d) urine specific gravity.

weight. 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.