Ch. 35 Heart Failure

9. The diagnosis of heart failure is usually confirmed by: a. a chest x-ray. b. an echocardiogram. c. an electrocardiogram. d. ventriculogram.

b

29. The drug of choice during cardiopulmonary resuscitation to suppress ventricular dysrhythmias is: a. atropine. b. epinephrine. c. lidocaine. d. morphine.

c

4. The nurse reminds Mr. Wolman to sleep with two pillows to elevate his head about 10 in. This position is recommended because: a. preload can be increased, thus enhancing cardiac output. b. pulmonary congestion can be reduced. c. venous return to the lungs can be improved, thus reducing peripheral edema. d. all of the above can help relieve his symptoms.

b

5. The primary cause of heart failure is: a. arterial hypertension. b. coronary atherosclerosis. c. myocardial dysfunction. d. valvular dysfunction.

b

7. 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 a heart failure classification of: a. I. b. II. c. III. d. IV.

b

1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and capillary refill time <3 seconds.

1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status.

2. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will: 1. Be able to ambulate in the hall by date of discharge. 2. Have an audible S1 and S2 with no S3 heard by end of shift. 3. Turn, cough, and deep breathe every two (2) hours. 4. Have a pulse oximeter reading of 98% by day two (2) of care.

2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life threatening.

7. The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking the medication with food.

2. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored.

5. The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention.

3. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.

12. The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.

4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome.

The nurse is preparing to administer a nitroglycerin patch to a patient. When providing teaching about the use of the patch, what should the nurse include? Avoid drugs to treat erectile dysfunction. Increase diet intake of high-potassium foods. Take an over-the-counter H2-receptor blocker. Avoid nonsteroidal antiinflammatory drugs (NSAIDS).

Avoid drugs to treat erectile dysfunction.

The home care nurse visits a patient with chronic heart failure. Which assessment findings would indicate acute decompensated heart failure (pulmonary edema)? Fatigue, orthopnea, and dependent edema Severe dyspnea and blood-streaked, frothy sputum Temperature is 100.4° F and pulse is 102 beats/min Respirations 26 breaths/min despite oxygen by nasal cannula

Severe dyspnea and blood-streaked, frothy sputum

24. Classic signs of cardiogenic shock include all of the following except: a. bradycardia. b. cerebral hypoxia. c. hypotension. d. oliguria.

a

20. A commonly prescribed diuretic that is given intravenously to produce a rapid diuretic effect is: a. Bumex. b. Lasix. c. Mykrox. d. Zaroxolyn.

b

21. Which statement by the patient with chronic heart failure should cause the nurse to determine that additional discharge teaching is needed? a. "I will call my health clinic if I wake up breathless at night." b. "I will look for sodium content on labels of foods and over-the-counter medicines." c. "I plan to organize my household tasks so I don't have to constantly go up and down the stairs." d. "I should weigh myself every morning and go on a diet if I gain more than 2 or 3 pounds in 2 days."

d. Further teaching is needed if the patient believes a weight gain of 2 to 3 pounds in 2 days is an indication for dieting. In a patient with heart failure, this type of weight gain reflects fluid retention and is a sign of heart failure that should be reported to the health care provider. The other options show patient understanding of the heart failure management teaching. (See Table 35-10.)

23. The nurse plans long-term goals for the patient who has had a heart transplant with the knowledge that what is the most common cause of death in heart transplant patients during the first year? a. Infection b. Heart failure c. Embolization d. Malignant conditions

a. Because of the need for long-term immunosuppressant therapy to prevent rejection, the patient with a transplant is at high risk for infection, a leading cause of death in transplant patients. Acute rejection episodes may also cause death in patients with transplants but many can be treated successfully with augmented immunosuppressive therapy. Malignancies occur in patients with organ transplants after taking immunosuppressants for a number of years.

6. Which initial physical assessment finding would the nurse expect to be present in a patient with acute left-sided heart failure? a. Bubbling crackles and tachycardia b. Hepatosplenomegaly and tachypnea c. Peripheral edema and cool, diaphoretic skin d. Frothy blood-tinged sputum and distended jugular veins

a. Clinical manifestations of acute left-sided heart failure are those of interstitial edema, with bubbling crackles and tachycardia, as well as tachypnea. Later frothy, bloodtinged sputum; severe dyspnea; and orthopnea develop with alveolar edema. Severe tachycardia and cool, clammy skin are present as a result of stimulation of the sympathetic nervous system from hypoxemia. Systemic edema reflected by jugular vein distention, peripheral edema, and hepatosplenomegaly are characteristic of right-sided heart failure.

14. When caring for the patient with heart failure, which medications or treatments require careful monitoring of the patient's serum potassium level to prevent further cardiac dysfunction (select all that apply)? a. Enalapril (Vasotec) b. Furosemide (Lasix) c. Inamrinone (Inocor) d. Spironolactone (Aldactone) e. Metoprolol CR/XL (Toprol XL)

b, d. Furosemide is a diuretic that eliminates potassium and spironalactone is a potassium-sparing diuretic that retains potassium. The other treatments and medications are used for patients with HF but they do not directly affect serum potassium levels

15. Priority Decision: A patient with chronic heart failure is treated with hydrochlorothiazide, digoxin, and lisinopril (Prinivil). To prevent the risk of digitalis toxicity with these drugs, what is most important that the nurse monitor for this patient? a. Heart rate (HR) b. Potassium levels c. Blood pressure (BP) d. Gastrointestinal function

b. Hypokalemia is one of the most common causes of digitalis toxicity because low serum potassium levels enhance ectopic pacemaker activity. When a patient is receiving potassium-losing diuretics, such as hydrochlorothiazide or furosemide, it is essential to monitor the patient's serum potassium levels to prevent digitalis toxicity. Monitoring the heart rate (HR) assesses for complications related to digoxin but does not prevent toxicity.

13. The patient with chronic heart failure is being discharged with a diuretic, a renin-angiotensin-aldosterone system (RAAS) inhibitor, and a β-adrenergic blocker. When received from the pharmacy, which medication should not be included for this patient? a. Losartan (Cozaar) b. Carvedilol (Coreg) c. Dopamine (Intropin) d. Hydrochlorothiazide (HCTZ)

c. Dopamine (Intropin) is a β-adrenergic agonist that is a positive inotrope given IV, not orally, and used for acute HF. Losartan (Cozaar) is an angiotensin II receptor blocker used for patients who do not tolerate angiotensin-converting enzyme inhibitors. Carvedilol (Coreg) is the β-adrenergic blocker that blocks the sympathetic nervous system's negative effects on the failing heart. Hydrochlorothiazide (HCTZ) is the diuretic.

17. The nurse monitors the patient receiving treatment for acute decompensated heart failure with the knowledge that marked hypotension is most likely to occur with the IV administration of which medication? a. Furosemide (Lasix) b. Nitroglycerin (Tridil) c. Milrinone (Primacor) d. Nitroprusside (Nipride)

d. Although all of these drugs may cause hypotension, nitroprusside is a potent dilator of both arteries and veins and may cause such marked hypotension that an inotropic agent (e.g., dobutamine) administration may be necessary to maintain the BP during its administration. Furosemide may cause hypotension because of diuretic-induced depletion of intravascular fluid volume. Nitroglycerin is a vasodilator and can decrease BP but not as severely as nitroprusside. It primarily dilates veins and increases myocardial oxygen supply. Milrinone has a positive inotropic effect in addition to direct arterial dilation.

4. The acronym FACES is used to help educate patients to identify symptoms of heart failure. What does this acronym mean? a. Frequent activity leads to cough in the elderly and swelling b. Factors of risk: activity, cough, emotional upsets, salt intake c. Follow activity plan, continue exercise, and know signs of problems d. Fatigue, limitation of activities, chest congestion/cough, edema, shortness of breath

d. FACES is used to teach patients signs and symptoms of worsening heart failure. F = Fatigue; A = Activity limitations; C = Congestion/cough; E = Edema; S = Shortness of breath. The other options are not correct

7. The nurse assesses the patient with chronic biventricular heart failure for paroxysmal nocturnal dyspnea (PND) by questioning the patient regarding a. the presence of difficulty breathing at night. b. frequent awakening to void during the night. c. the presence of a dry, hacking cough when resting. d. the use of two or more pillows to help breathing during sleep

d. Paroxysmal nocturnal dyspnea (PND) is awakening from sleep with a feeling of suffocation and a need to sit up to be able to breathe and patients learn that sleeping with the upper body elevated on several pillows helps to prevent PND. Orthopnea is an inability to breathe effectively when lying down and nocturia occurs with heart failure as fluid moves back into the vascular system during recumbency, increasing renal blood flow.

22. The evaluation team for cardiac transplantation is evaluating patients. Which patient is most likely to receive the most benefit from a new heart? a. A 24-year-old man with Down syndrome who has received excellent care from parents in their 60s b. A 46-year-old single woman with a limited support system who has alcohol-induced cardiomyopathy c. A 60-year-old man with inoperable coronary artery disease who has not been compliant with lifestyle changes and rehabilitation programs d. A 52-year-old woman with end-stage coronary artery disease who has limited financial resources but is emotionally stable and has strong social support

d. The 52-year-old woman does not have any contraindications for cardiac transplantation, even though she lacks the indication of adequate financial resources. The postoperative transplant regimen is complex and rigorous and patients who have not been compliant with other treatments or who might not have the means to understand the care would not be good candidates. A history of drug or alcohol abuse is usually a contraindication to heart transplant.

6. The dominant function in cardiac failure is: a. ascites. b. hepatomegaly. c. inadequate tissue perfusion. d. nocturia.

c

At a clinic visit, the nurse provides dietary teaching for a patient recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement? "I will limit the amount of milk and cheese in my diet." "I can add salt when cooking foods but not at the table." "I will take an extra diuretic pill when I eat a lot of salt." "I can have unlimited amounts of foods labeled as reduced sodium."

"I will limit the amount of milk and cheese in my diet."

An older adult patient with chronic heart failure (HF) and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed to continue at home. What is the best response by the nurse? "The medication prevents blood clots from forming in your heart." "The medication dissolves clots that develop in your coronary arteries." "The medication reduces clotting by decreasing serum potassium levels." "The medication increases your heart rate so that clots do not form in your heart."

"The medication prevents blood clots from forming in your heart."

3. What describes the action of the natriuretic peptides and nitric oxide in their counterregulatory processes in response to heart failure (HF)? a. Excretion of potassium b. Increased release of ADH c. Vasodilation and decreased blood pressure d. Decreased glomerular filtration rate and edema

. c. Both the natriuretic peptides and nitric oxide contribute to vasodilation, decreased blood pressure, and decreased afterload. The natriuretic peptides also increase excretion of sodium by increasing glomerular filtration rate and diuresis (renal effects) as well as interfere with ADH release and inhibit aldosterone and renin secretion (hormonal effects).

11. Which medication is currently approved only for use with African American patients for hypertension and angina? a. Captopril (Capoten) b. Nitroglycerin (Nitro-Bid) c. Spironolactone (Aldactone) d. Isosorbide dinitrate and hydralazine (BiDil)

. d. Isosorbide dinitrate and hydralazine (BiDil) is currently used only with African American patients for hypertension and angina. Captopril (Capoten) is used only for hypertension by all patients. Nitroglycerin (Nitro-Bid) is used with hydralazine (Apresoline) for patients who cannot tolerate renin-angiotensin-aldosterone system inhibitors for heart failure management. Spironolactone (Aldactone) is used for hypertension

A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the physician and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side-lying position

1, 2, 3, 4 Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

8. The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation.

6. The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan.

1. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF.

A patient is scheduled for a heart transplant. What is a major cause of death beyond the first year after a heart transplant? Infection Acute rejection Immunosuppression Cardiac vasculopathy

Cardiac vasculopathy

3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2. The client should not take digoxin if the radial pulse is less than 60. 3. The client should be on a low-sodium diet to prevent water retention.

11. The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium.

728. A client is being treated for acute congestive heart failure with intravenously administered bumetanide (Bumex). The vital signs are as follows: blood pressure, 100/60 mm Hg; pulse, 96 beats/min; and respirations, 24 breaths/min. After the initial dose, which of the following is the priority assessment? 1. Monitoring weight loss 2. Monitoring urine output 3. Monitoring blood pressure 4. Monitoring potassium level

3 Rationale: Hypotension is a common side effect associated with the use of this medication. Options 1, 2, and 4 also require assessment but are not the priority.

10. The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough.

3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client.

9. The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done.

4. The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment.

4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position.

4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead.

A patient admitted with heart failure is anxious and reports shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety? (Select all that apply.) Administer ordered morphine sulfate. Position patient in a semi-Fowler's position. Position patient on left side with head of bed flat. Instruct patient on the use of relaxation techniques. Use a calm, reassuring approach while talking to patient.

Administer ordered morphine sulfate. Position patient in a semi-Fowler's position. Instruct patient on the use of relaxation techniques. Use a calm, reassuring approach while talking to patient.

A patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? Review urinary output for the previous 24 hours. Restrict the patient's oral fluid intake to 500 mL/day. Assist the patient to a sitting position with arms on the overbed table. Teach the patient to use pursed-lip breathing until the dyspnea subsides.

Assist the patient to a sitting position with arms on the overbed table.

An asymptomatic patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before dangling the patient on the bedside, what should the nurse assess first? Urine output Heart rhythm Breath sounds Blood pressure

Blood pressure

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? Urine output Lung sounds Blood pressure Respiratory rate

Blood pressure

A patient with a long-standing history of heart failure recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? Taper the patient off his current medications. Continue education for the patient and his family. Pursue experimental therapies or surgical options. Choose interventions to promote comfort and prevent suffering.

Choose interventions to promote comfort and prevent suffering.

What should the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure? Acute anxiety Hypotension and tachycardia Peripheral edema and weight gain Paroxysmal nocturnal dyspnea (PND)

Hypotension and tachycardia

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient? (Select all that apply.) Left ventricular function is documented Controlling dysrhythmias will eliminate HF Prescription for digoxin (Lanoxin) at discharge Prescription for angiotensin-converting enzyme inhibitor at discharge Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

Left ventricular function is documented Prescription for angiotensin-converting enzyme inhibitor at discharge Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

The nurse is administering a dose of Digitalis (digoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom? Muscle aches Constipation Loss of appetite Pounding headache

Loss of appetite

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix). What outcome would demonstrate medication effectiveness? Promote vasodilation. Reduction of preload. Decrease in afterload. Increase in contractility.

Reduction of preload.

After having a myocardial infarction (MI), the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108 beats/min. What should the nurse suspect is happening? Chronic HF Left-sided HF Right-sided HF Acute decompensated HF

Right-sided HF

The nurse prepares to administer digoxin 0.125 mg to a patient admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication? Prothrombin time Urine specific gravity Serum potassium level Hemoglobin and hematocrit

Serum potassium level

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to acute decompensated heart failure (ADHF)? Take medications as prescribed. Use oxygen when feeling short of breath. Direct questions only to the health care provider. Encourage most activity in the morning when rested.

Take medications as prescribed.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What is the priority action by the nurse? Withhold the daily dose until the following day. Withhold the dose and report the potassium level. Give the digoxin with a salty snack, such as crackers. Give the digoxin with extra fluids to dilute the sodium level.

Withhold the dose and report the potassium level.

1. The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at various points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following measurements except: a. central venous pressure (CVP). b. pulmonary artery capillary pressure (PACP). c. pulmonary artery obstructive pressure (PAOP). d. pulmonary artery wedge pressure (PAWP).

a

13. A primary classification of medications used in the treatment of systolic heart failure is: a. angiotensin-converting enzyme inhibitors. b. beta-blockers. c. diuretics. d. calcium-channel blockers.

a

15. An example of a potassium-sparing diuretic that might be prescribed for a person with congestive heart failure is: a. Aldactone. b. Mykrox. c. Zaroxolyn. d. Lasix.

a

17. The primary underlying disorder of pulmonary edema is: a. decreased left ventricular pumping. b. decreased right ventricular elasticity. c. increased left atrial contractility. d. increased right atrial resistance.

a

2. Hemodynamic monitoring by means of a multilumen pulmonary artery catheter can provide detailed information about: a. preload. b. afterload. c. cardiac output. d. all of the above.

a

27. The most reliable sign of cardiac arrest is: a. absence of a pulse. b. cessation of respirations. c. dilation of the pupils. d. inaudible heart sounds

a

Mr. Wolman is to be discharged from the hospital to home. He is 79 years old, lives with his wife, and has just recovered from mild pulmonary edema secondary to congestive heart failure. 2. The sequence of pathophysiologic events is triggered by: a. elevated left ventricular end-diastolic pressure. b. elevated pulmonary venous pressure. c. increased hydrostatic pressure. d. impaired lymphatic drainage.

a

1. Which statements accurately describe heart failure (select all that apply)? a. A common cause of diastolic failure is left ventricular hypertrophy. b. A primary risk factor for heart failure is coronary artery disease (CAD). c. Systolic heart failure results in a normal left ventricular ejection fraction. d. Systolic failure is characterized by abnormal resistance to ventricular filling. e. Hypervolemia precipitates heart failure by decreasing cardiac output and increasing oxygen consumption.

a, b. Diastolic failure is characterized by abnormal resistance to ventricular filling. Coronary artery disease (CAD), advanced age, and hypertension are all risk factors for heart failure (HF). Ejection fraction is decreased in systolic HF. Dysrthythmia precipitates HF with decreased cardiac output (CO) and increased workload and oxygen requirements of the myocardium.

28. Brain damage occurs with cessation of circulation after an approximate interval of: a. 2 minutes. b. 4 minutes. c. 6 minutes. d. 8 minutes.

b

4. The most frequent cause for hospitalization for people older than 75 years of age is: a. angina pectoris. b. heart failure. c. hypertension. d. pulmonary edema

b

16. The health care provider prescribes spironolactone (Aldactone) for the patient with chronic heart failure. What diet modifications related to the use of this drug should the nurse include in the patient teaching? a. Decrease both sodium and potassium intake b. Increase calcium intake and decrease sodium intake c. Decrease sodium intake and increase potassium intake d. Decrease sodium intake and the use of salt substitutes for seasoning

a. Spironolactone is a potassium-sparing diuretic and when it is the only diuretic used in the treatment of heart failure, moderate to low levels of potassium intake should be maintained to prevent development of hyperkalemia. Sodium intake is usually reduced to at least 2400 mg/day in patients with heart failure but salt substitutes cannot be freely used because most contain high concentrations of potassium. Calcium intake is not increased.

11. According to the American College of Cardiology and the American Heart Association, a patient presenting with left ventricular dysfunction without symptoms of heart failure would be classified as: a. stage A. b. stage B. c. stage C. d. stage D.

b

14. The nurse knows that this angiotensin-converting enzyme inhibitor ordered by the physician has a rapid onset of action within 15 minutes. a. Altace b. Capoten c. Lotensin d. Vasotec

b

23. Cardiogenic shock is pump failure that occurs primarily as the result of: a. coronary artery stenosis. b. left ventricular damage. c. myocardial ischemia. d. right atrial flutter.

b

5. What is the pathophysiologic mechanism that results in the pulmonary edema of left-sided heart failure? a. Increased right ventricular preload b. Increased pulmonary hydrostatic pressure c. Impaired alveolar oxygen and carbon dioxide exchange d. Increased lymphatic flow of pulmonary extravascular fluid

b. In left-sided heart failure, blood backs up into the pulmonary veins and capillaries. This increased hydrostatic pressure in the vessels causes fluid to move out of the vessels and into the pulmonary interstitial space. When increased lymphatic flow cannot remove enough fluid from the interstitial space, fluid moves into the alveoli, resulting in pulmonary edema and impaired alveolar oxygen and carbon dioxide exchange. Initially the right side of the heart is not involved.

9. A patient with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction (LVEF) of 18%. To decrease the risk of complications from these conditions, what drug does the nurse anticipate giving? a. Diuretics b. Anticoagulants c. β-Adrenergic blockers d. Potassium supplements

b. Thrombus formation occurs in the heart when the chambers do not contract normally and empty completely. Both atrial fibrillation and very low left ventricular output (LVEF <20%) lead to thrombus formation, which is treated with anticoagulants to prevent the release of emboli into the circulation as well as antidysrhythmics or cardioversion to control atrial fibrillation.

10. A key diagnostic laboratory test for heart failure is the: a. blood urea nitrogen (BUN). b. complete blood cell count. c. B-type natriuretic peptide. d. serum electrolyte counts.

c

16. Digitalis toxicity is a key concern in digitalis therapy. A therapeutic digitalis level should be: a. 0.25 to 0.35 mg/mL. b. 0.30 to 4.0 mg/mL c. 0.5 to 2.0 mg/mL. d. 2.5 to 4.0 mg/mL.

c

26. A clinical manifestation of pericardial effusion is: a. widening pulse pressure. b. a decrease in venous pressure. c. shortness of breath. d. an increase in blood pressure.

c

18. A 2400-mg sodium diet is prescribed for a patient with chronic heart failure. The nurse recognizes that additional teaching is necessary when the patient makes which statement? a. "I should limit my milk intake to 2 cups a day." b. "I can eat fresh fruits and vegetables without worrying about sodium content." c. "I can eat most foods as long as I do not add salt when cooking or at the table." d. "I need to read the labels on prepared foods and medicines for their sodium content."

c. All foods that are high in sodium should be eliminated in a 2400-mg sodium diet, in addition to the elimination of salt during cooking. Examples include obviously salted snack foods as well as pickles, processed prepared foods, and many sauces and condiments.

10. Which diagnostic test is most useful in differentiating dyspnea related to pulmonary effects of heart failure from dyspnea related to pulmonary disease? a. Exercise stress testing . Cardiac catheterization c. B-type natriuretic peptide (BNP) levels b d. Determination of blood urea nitrogen (BUN)

c. B-type natriuretic peptide (BNP) is released from the ventricles in response to increased blood volume in the heart and is a good marker for heart failure. If BNP is elevated, shortness of breath is due to heart failure; if BNP is normal, dyspnea is due to pulmonary disease. BNP opposes the actions of the renin-angiotensin-aldosterone system, resulting in vasodilation and reduction in blood volume. Exercise stress testing and cardiac catheterization are more important tests to diagnose coronary artery disease and although the blood urea nitrogen (BUN) may be elevated in heart failure, it is a reflection of decreased renal perfusion. (See Table 32-6.)

12. Priority Decision: A patient is admitted to the emergency department with acute decompensated heart failure (ADHF). Which IV medication would the nurse expect to administer first? a. Digoxin (Lanoxin) b. Morphine sulfate c. Nesiritide (Natrecor) d. Bumetanide (Bumex)

c. Nesiritide (Natrecor) is a recombinant form of a natriuretic peptide that decreases preload and afterload by reducing pulmonary artery wedge pressure (PAWP) and systolic BP which decreases the workload of the heart for short-term emergency treatment of acute decompensated heart failure (ADHF). Digoxin (Lanoxin) requires a loading dose and time to work, so it is not recommended for emergency treatment of ADHF. Morphine sulfate relieves dyspnea but has more adverse events and mortality. Bumetanide (Bumex) will decrease fluid volume but also will decrease potassium levels and activate the sympathetic nervous system and renin-angiotensin-aldosterone system, which can exacerbate HF symptoms.

20. The nurse determines that treatment of heart failure has been successful when the patient experiences a. weight loss and diuresis. b. warm skin and less fatigue. c. clear lung sounds and decreased HR. d. absence of chest pain and improved level of consciousness (LOC).

c. Successful treatment of heart failure is indicated by an absence of symptoms of pulmonary edema and hypoxemia, such as clear lung sounds and a normal HR. Weight loss and diuresis, warm skin, less fatigue, and improved LOC may occur without resolution of pulmonary symptoms. Chest pain is not a common finding in heart failure unless coronary artery perfusion is impaired.

12. The treatment for cardiac failure is directed at: a. decreasing oxygen needs of the heart. b. increasing the cardiac output by strengthening muscle contraction or decreasing peripheral resistance. c. reducing the amount of circulating blood volume. d. all of the above.

d

18. Pulmonary edema is characterized by: a. elevated left ventricular end-diastolic pressure. b. a rise in pulmonary venous pressure. c. increased hydrostatic pressure. d. all of the above alterations.

d

19. With pulmonary edema, there is usually an alteration in: a. afterload. b. contractility. c. preload. d. all of the above.

d

21. Morphine is given in acute pulmonary edema to redistribute the pulmonary circulation to the periphery by decreasing: a. peripheral resistance. b. pulmonary capillary pressure. c. transudation of fluid. d. all of the above.

d

22. A recommended position for a patient in acute pulmonary edema is: a. prone, to encourage maximum rest, thereby decreasing respiratory and cardiac rates. b. semi-Fowler's, to facilitate breathing and promote pooling of blood in the sacral area. c. Trendelenburg, to drain the upper airways of congestion. d. upright with the legs down, to decrease venous return.

d

25. The nurse expects that positive inotropic medications would be administered to treat cardiogenic shock, with the exception of: a. Adrenalin. b. Dobutrex. c. Intropin. d. Levophed.

d

3. Nursing measures in hemodynamic monitoring include assessing for localized ischemia caused by inadequate arterial flow. The nurse should: a. assess the involved extremity for color temperature. b. check for capillary filling. c. evaluate pulse rate. d. do all of the above.

d

3. The nurse advises Mr. Wolman to rest frequently at home. This advice is based on the knowledge that rest: a. decreases blood pressure. b. increases the heart reserve. c. reduces the work of the heart. d. does all of the above.

d

5. Mr. Wolman takes 0.25 mg of digoxin once a day. The nurse should tell him about signs of digitalis toxicity, which include: a. anorexia. b. bradycardia and tachycardia. c. nausea and vomiting. d. all of the above.

d

6. Mr. Wolman also takes Lasix (40 mg) twice a day. He is aware of signs related to hypokalemia and supplements his diet with foods high in potassium, such as: a. bananas. b. raisins. c. orange juice. d. all of the above.

d

8. On assessment, the nurse knows that the presence of pitting edema indicates fluid retention of at least: a. 4 lb. b. 6 lb. c. 8 lb. d. 10 lb.

d