Ch. 29 PrepU Mgmnt of Pts w. Complications from Heart Disease
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 atrial function Right ventricular function Left ventricular function Right atrial function
C 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.
Which of the following body system responses correlates with systolic heart failure (HF)? Decrease in renal perfusion Dehydration Vasodilation of skin Increased blood volume ejected from ventricle
A 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.
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 Measuring and recording fluid intake and output Checking the client's lungs for crackles during every shift Assessing the client's vital signs every 4 hours
A 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.
A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing decompensated heart failure with pulmonary edema. tuberculosis. acute exacerbation of chronic obstructive pulmonary disease. bilateral pneumonia.
A Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated heart failure with pulmonary edema. These signs can be confused with pneumonia and tuberculosis, however the patient reveals course crackles upon auscultation which is indicitive of pulmonary edema. A patient with acute COPD would have diminished lung sounds bilaterally.
A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? White blood cell (WBC) count Potassium Platelet count Calcium
B Diuretics, such as furosemide (Lasix), are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin (Lanoxin), and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.
Which of the following medications is a human brain natriuretic peptide (BNP) preparation? Captopril Natrecor Enalapril Metoprolol
B 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.
Which describes difficulty breathing when a client is lying flat? Bradypnea Orthopnea Paroxysmal nocturnal dyspnea (PND) Tachypnea
B Orthopnea occurs when the client is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.
The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause decreased preload. The student correctly answers which of the following? Application of antiembolytic stockings Administration of a vasodilating drug (as ordered by a physician) Maintaining the client's legs elevated Ambulation
B 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 (antiembolytic stockings) or preventing blood from pooling in the extremities will increase preload.
A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing intervention? Administer angiotensin-converting enzyme inhibitors Administer diuretics Assess oxygen saturation Administer angiotensin II receptor blockers
C Assessment is priority 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.
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? high urine output dry mucous membranes pulmonary crackles hypertension
C 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 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 corpulmonale The development of chronic obstructive pulmonary disease (COPD) The development of left-sided heart failure The development of right-sided heart failure
C 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. Corpulmonale is a condition in which the heart is affected secondarily by lung damage.
The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience? Increased perspiration Sleeping in a chair or recliner Increased urine output Gradual unexplained weight gain
D Clients with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention. Left-sided heart failure produces paroxysmal nocturnal dyspnea, which may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Right-sided heart failure does not cause increased perspiration or increased urine output.
The nurse is administering nitroglycerin, which he knows decreases preload as well as afterload. Preload refers to which of the following? The amount of resistance to the ejection of blood from the ventricles The force of the contraction related to the sympathetic nervous system Fluid overload and tissue perfusion status The amount of blood presented to the ventricles just before systole
D Preload is the amount of blood presented to the ventricles just before systole. It increases pressure in the ventricles, which stretches the ventricle wall. Like a piece of elastic, the muscle fibers need to be stretched to produce optimal recoil and forceful ejection of blood. Afterload refers to the amount of resistance to the ejection of blood from the ventricle. To eject blood, the ventricles much overcome the resistance caused by tension in the aorta, systemic vessels, and pulmonary artery.
A client has had an echocardiogram to measure ejection fracton. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects? 40% 55% 45% 50%
B Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.
Which of the following would be inconsistent as a lifestyle change directive for the patient diagnosed with heart failure? Push fluids Avoid excess alcohol Restrict dietary sodium Abstinence from smoking
A Lifestyle recommendations include restriction of dietary sodium; avoidance of excessive fluid intake, alcohol, and smoking; weight reduction when indicated; and regular exercise.
Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Electrocardiogram (ECG) Echocardiogram Serum electrolytes Blood urea nitrogen (BUN)
B 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.
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 fourth heart sound (S4). a first heart sound (S1). a murmur. a third heart sound (S3).
D 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 has been prescribed furosemide (Lasix) 80 mg twice daily. The cardiac monitor technician informs the nurse that the client has started having rare premature ventricular contractions followed by runs of bigeminy lasting 2 minutes. During the assessment, the nurse determines that the client is asymptomatic and has stable vital signs. Which of the following actions should the nurse perform next? Call the physician. Summon the nurse-manager. Administer potassium. Check the client's potassium level.
D The client is asymptomatic but has had a change in heart rhythm. More information is needed before calling the physician. Because the client is taking furosemide (Lasix), a potassium-wasting diuretic, the next action would be to check the client's potassium level. The nurse would then call the physician with a more complete database. The physician will need to be notified after the nurse checks the latest potassium level. Calling the nurse-manager is not indicated at this time. Administering potassium requires a physician's order.
The nurse identifies which symptom as a characteristic of right-sided heart failure? Cough Dyspnea Pulmonary crackles Jugular vein distention (JVD)
D JVD is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.
A client is receiving furosemide, a loop diuretic, to prevent fluid overload. The order is for 50 mg intraveneous now. The pharmacy supplies furosemide 80 mg per 2 mL. How many mL will the nurse give the client? Enter the correct number ONLY.
1.25 mL
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-potassium diet Low-sodium diet Low-cholesterol diet Low-fat diet
B 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 has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment? increased cardiac output hypertension moist, gurgling respirations drowsiness, numbness
C Clients with acute pulmonary edema experience sudden dyspnea, wheezing, orthopnea, cough, cyanosis, and tachycardia. Respirations sound moist or gurgling. Drowsiness and numbness are not considered issues. Increased cardiac output is not part of this checklist. Hypertension is not an immediate symptom.
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client? Pedal edema Nausea Pulmonary congestion Jugular venous distention
C 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.
The diagnosis of heart failure is usually confirmed by which of the following? Chest x-ray Ventriculogram Electrocardiogram (12-lead) Echocardiogram
D Although the chest X-ray can indicate cardiomegaly and the ECG can indicate a left ventricular abnormality, it is the echocardiogram that is diagnostic. This test measures ejection fraction (EF) which, if greater than 40% and accompanied with signs and symptoms of heart failure, indicates diastolic dysfunction and impaired ventricular relaxation.
Which is a key diagnostic indicator of heart failure? Blood urea nitrogen (BUN) Complete blood count (CBC) Creatinine Brain natriuretic peptide (BNP)
D BNP is the key diagnostic indicator of HF. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. BUN, creatinine, and a CBC are included in the initial workup.
The nurse recognizes which symptom as a classic sign of cardiogenic shock? High blood pressure Increased urinary output Hyperactive bowel sounds Restlessness and confusion
D 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).
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? Bilateral crackles Cyanosis of the lips Productive cough Leg edema
D 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.
The nurse identifies which symptom as a manifestation of right-sided heart failure (HF)? Accumulation of blood in the lungs Congestion in the peripheral tissues Reduction in cardiac output Reduction in forward flow
B Right-sided HF, failure of the right ventricle, results in congestion in the peripheral tissues and the viscera and causes systemic venous congestion and a reduction in forward flow. Left-sided HF refers to failure of the left ventricle; it results in pulmonary congestion and causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues.
A nurse suspects that a client has digoxin toxicity. The nurse should assess for: hearing loss. gait instability. vision changes. decreased urine output.
C 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.
Which feature is the hallmark of systolic heart failure? Low ejection fraction (EF) Pulmonary congestion Basilar crackles Limited activities of daily living (ADLs)
A A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.
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 Sodium level of 135 Hemoglobin of 12 BNP of 100
A 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 patient has been diagnosed with systolic heart failure. The nurse would expect the patient's ejection fraction to be at which level? Severely reduced Normal Slightly reduced High
A The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure.
A physician orders digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? Magnesium level of 2.5 mg/dl Potassium level of 2.8 mEq/L Calcium level of 7.5 mg/dl Sodium level of 152 mEq/L
B 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.
The nurse is working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for the nurse to closely monitor an older adult receiving digitalis preparations for cardiac disorders? Older adults are at increased risk for hyperthyroidism. Older adults are at increased risk for toxicity. Older adults are at increased risk for asthma. Older adults are at increased risk for cardiac arrests.
B 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.
Which of the following therapies are for patient who have advanced heart failure (HF) after all other therapies have failed? Implantable cardiac defibrillator (ICD) Ventricular access device Heart transplant Cardiac resynchronization therapy
C 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.
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? The client says he has been hungry in the evening. The client says that he has been urinating less frequently at night. The client says he is short of breath when ambulating. The client says his rings have become tight and are difficult to remove.
D 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 nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? Decreased urinary output Tachycardia Hypotension Dyspnea on exertion
D 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 total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD? An LVAD only supports a failing left ventricle. It never needs batteries. It is specifically designed for long-term use. It is designed for extremely active patients.
A A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.
Which is a characteristic of right-sided heart failure? Jugular vein distention Dyspnea Cough Pulmonary crackles
A Jugular vein distention is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.
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? Blood urea nitrogen (BUN) B-type natriuretic peptide (BNP) Serum electrolytes Complete blood count (CBC)
B 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).
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid: dried peas. canned peas. ready-to-eat cereals. angel food cake.
B 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.
Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest? I II III IV
D 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.
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. Observe for mist in the endotracheal tube. Attach a pulse oximeter probe and obtain values. Listen for breath sounds over the epigastrium.
A 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 is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client? Digoxin immune FAB Warfarin Ibuprofen Amlodipine
A Digibind binds with digoxin and makes it unavailable for use. The digibind dosage is based on the digoxin level and the patient's weight. Ibuprofen, warfarin, and amlodipine are not used to reverse the effects of digoxin.
A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate? Morphine sulfate Dopamine Furosemide Nitroglycerin
A Morphine seems to help relieve respiratory symptoms by depressing higher cerebral centers, thus relieving anxiety and slowing respiratory rate. Morphine also promotes muscle relaxation and reduces the work of breathing. Furosemide is a loop diuretic and will decrease fluid accumulation but will not reduce anxiety. Nitroglycerin will promote smooth muscle relaxation in the vessel walls and will relieve pain but not reduce anxiety. Dopamine is an inotrope that will increase the force of ventricular contraction but will not alleviate anxiety.
The nurse does an assessment on a patient who is admitted with a diagnosis of right-sided heart failure. The nurse knows that a significant sign is which of the following? Oliguria S3 ventricular gallop sign Pitting edema Decreased O2 saturation levels
C 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.
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? Encourage increased intake of vegetables with natural sodium. Avoid the intake of canned fruit and fruit juices. Encourage increased intake of red meat. Avoid the intake of processed and commercially prepared foods.
D 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.
