MedSurg 351 Final

Nursing Intervention for HF

-Daily weights -I & O -administer O2 therapy -Semi-fowlers position

What are manifestations of left-sided heart failure?

-Decreased cardiac output -Pulmonary congestion

What is the protocol for nitroglycerin (SL NTG)?

-Give 1 tablet -Relief in 5 minutes -May repeat every 5 minutes for up to 3 doses. -If no relief, call EMS -Patient teaching: proper use and storage -Prophylactic use -Long-acting nitrates

What is the purpose of a coronary agniography?

-It is used to identify coronary blockages by using contrast medium

C-reactive protein (CRP)

-Marker for inflammation

What actions of care would you take for a patient with angina?

-Position upright, apply oxygen. -Assess: VS, heart and breath sounds -Continuous ECG monitor -Pain relief--> NTG; IV opioid if needed. -obtain cardiac biomarkers -obtain chest x-ray -Provide support, reduce anxiety

What are some characteristics of right-sided heart failure?

-Right ventricle does not pump effectively -Fluid back up in the venous system, fluid moves into tissues and organs

What is cardiac catheterization used for?

-Right-sided to measure pressure -Left-sided to evaluate coronary arteries

What is an echocardiogram?

-Ultrasound of the heart. -It can be done with or without contrast. -Provides info regarding structures and motions of the hart. -Measures ejection fraction

How do you optimize myocardial perfusion?

-administer oxygen -administer antiplatelet and lipid-lowering drugs in addition to Nitrates and ACE inhibitors, Beta Blockers, and Calcium channel blockers

Pulmonary Edema Manifestation

-anxious, pale, cyanotic -dyspnea -orthopnea, tachypnea -use of accessory muscles -Cough with frothy, blood-tinged sputum -crackles and wheezes, tachycardia -hypotension or hypertension

Pericardial Tamponade

-due to fluid accumulation in pericardial sac -hypotension, muffled heart sounds, JVD -Notify provider immediately

What are signs and symptoms of Heart Failure?

-fatigue, dyspnea, orthopnea -nocturnal dyspnea -cough, tachycardia, palpitations, edema -changes in urine output -nocturia, skin changes -neurological manifestations -mental status and behavioral changes -sleep problmes -chest pain, weight changes

What are some signs and symptoms of decreased cardiac output?

-fatigue, weakness -oliguria during the day and nocturia at night -angina, confusion, restlessness -dizziness, tachycardia, palpitations -pallor, weak peripheral pulses, cool extremities

What are signs of pulmonary congestion?

-hacking cough, worse at night -dyspnea or breathlessness -crackles or wheezes in lungs -Frothy pink-tinged sputum, Tachypnea

Nursing Actions for Pulmonary Edema

-high fowlers -O2 -mechanical ventilation -IV meds (diuretics, morphine)

What are some primary risk factors for Heart Failure

-hypertension -comorbidities-

What are contributing factors of Prinzmetal's angina

-increased levels of certain substances -Narrowed blood vessels from medications -exposure to cold weather

Signs and symptoms of systemic congestion

-jugular vein distention -enlarged liver and spleen -anorexia and nausea -dependent edema -distended abdomen -swollen hands and fingers -polyuria at night -weight gain -increased BP (from excess volume) -Decreased BP (from failure)

Nutritional Therapy for Heart Failure

-low sodium (2g/day) -fluid restriction -daily weights -weight gain of 3 lbs over 2 days or a 3-5 lb gain over a week should be reported to HCP

What are some signs and symptoms of chronic stable angina

-may deny pain -have pressure, heaviness or discomfort in chest. -may be accompanied by dyspnea or fatigue -no change with position or breathing

What is some treatment options for unstable and prinzmetal's angina?

-moderate exercise -SL NTG -Calcium channel blockers -may resolve on its own.

What does troponin test for?

-myocardial (heart muscle injury). -When there is damage to the heart, such as during a heart attack (myocardial infarction), cardiac troponin is released into the bloodstream.

What is the goal of treatment for chronic stable angina?

-reduce O2 demand and/or increase O2 supply

What are the characteristics of Left-Sided Heart Failure?

-results from inability of LV to empty adequately during systole or fill adequately during diastole. -blood backs up in the left atrium -Increased pulmonary hydrostatic pressure causes fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli -This results in pulmonary congestion and edema.

When does troponin levels peak?

10-24 hours

A patient returns to the cardiac observation area following a cardiac catheterization with coronary angiography. Which of the following assessments would require immediate action by the nurse? 1. Pedal pulses are 2+ bilaterally 2. Apical pulse is 54 beats minute 3. Mean arterial pressure is 72 mm Hg 4. ST-segment elevation develops on the ECG.

4. ST segment elevation develops on the ECG. ST-segment elevation on the electrocardiogram (ECG) is a critical finding that suggests myocardial ischemia or infarction (heart attack). It indicates that there may be a blockage in the coronary arteries, limiting blood flow to the heart muscle. Immediate intervention is needed to address the ischemia and prevent further damage to the heart tissue. The nurse should notify the healthcare provider promptly and initiate appropriate interventions, which may include medications or procedures to restore blood flow to the affected area of the heart. This is a priority because it represents a potentially life-threatening situation that requires urgent attention.

A patient arrives at an urgent care center after experiencing unrelenting substernal and epigastric pain and pressure for about 12 hours. The nurse reviews lab results with the understanding that at this point in time, a myocardial infarction would be indicated by peak levels of A. Troponin T B. Homocysteine C. Creatine Kinase-MB D. Type b natriuretic peptide

A. Troponin T

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires immediate action by the nurse? a. O2 saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Heart rate of 106 beats/min d. Urine output of 50 mL over 2 hours

ANS: A A decrease in O2 saturation to less than 92% indicates hypoxemia, and the nurse would start supplemental O2 immediately. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output may also indicate worsening heart failure and require nursing actions, but the low O2 saturation rate requires the most immediate nursing action.

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action would the nurse perform first? a. Attach the heart monitor. b. Obtain the blood pressure. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

ANS: A Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible.

A patient who developed chest pain 4 hours ago may be having a myocardial infarction. Which laboratory test result would be most helpful in indicating myocardial damage? a. Troponins b. Myoglobin c. Homocysteine (Hcy) d. Creatine kinase-MB (CK-MB)

ANS: A Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. High-sensitivity troponin (hs-cTnT, hs-cTnI) assays provide even earlier detection of a heart event, within 1-3 hours.

A patient in the intensive care unit who has acute decompensated heart failure (ADHF) reports severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been prescribed for the patient. Which action would the nurse take first? a. Give PRN IV morphine sulfate 4 mg. b. Give PRN IV diazepam (Valium) 2.5 mg. c. Increase nitroglycerin infusion by 5 mcg/min. d. Increase dopamine infusion by 2 mcg/kg/min.

ANS: A Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate rapidly to the health care provider? a. High troponin I level b. Increased triglyceride level c. Very low homocysteine level d. Elevated C-reactive protein level

ANS: A The elevation in troponin I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results indicate increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention.

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will sit down before I put the nitroglycerin under my tongue." b. "I will check my pulse rate before I take any nitroglycerin tablets." c. "I will put the nitroglycerin patch on as soon as I get any chest pain." d. "I will remove the nitroglycerin patch before taking sublingual nitroglycerin."

ANS: A The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

How would the nurse document a loud humming sound auscultated over the patient's abdominal aorta? a. Thrill b. Bruit c. Murmur d. Normal finding

ANS: B A bruit is the sound created by turbulent blood flow in an artery. Auscultating a bruit in an artery is not normal and indicates pathology. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart.

The nurse is developing a teaching plan for a patient with coronary artery disease (CAD). Which factor would the nurse focus on during the teaching session? a. Family history of coronary artery disease b. Elevated low-density lipoprotein (LDL) level c. Greater risk associated with the patient's gender d. Increased risk of cardiovascular disease with aging

ANS: B Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain may be from an acute myocardial infarction? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

The nurse is admitting a patient for a cardiac catheterization and coronary angiogram. Which information is important for the nurse to communicate to the health care provider before the test? a. The patient's pedal pulses are +1. b. The patient is allergic to contrast dye. c. The patient had a heart attack 1 year ago. d. The patient has not eaten anything today.

ANS: B Patients who have allergies to contrast dye will require treatment with medications, such as corticosteroids and antihistamines before the angiogram. The other information may be communicated to the health care provider but will not require a change in the usual pre-cardiac catheterization orders or medications.

Which patient statement indicates that the nurse's teaching about carvedilol (Coreg) for preventing anginal episodes has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."

ANS: B Patients who have been taking -adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking -adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries.

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor is on a low-sodium diet. The patient tells the home health nurse about a 5-lb weight gain in the past 3 days. Which action is the nurse's priority? a. Teach the patient about restricting dietary sodium. b. Assess the patient for manifestations of acute heart failure. c. Ask the patient about the use of the prescribed medications. d. Have the patient recall the dietary intake for the past 3 days.

ANS: B The 5-lb weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

ANS: B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse will also monitor heart rate and blood pressure and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL b. Patient with stable angina whose chest pain has recently increased in frequency c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

ANS: B The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are more stable.

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient would the nurse assess first? a. A patient who has dizziness after a dose of captopril. b. A patient who has new-onset confusion and restlessness. c. A patient who is receiving oxygen and has crackles in the bilateral lung bases. d. A patient who is receiving IV nesiritide (Natrecor), with a BP of 100/62.

ANS: B The patient who has neurological manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also would be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.

A patient who has chest pain is admitted to the emergency department (ED), and all of the following items are prescribed. Which one would the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. Electrocardiogram (ECG) d. Insertion of a peripheral IV

ANS: C

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram

ANS: C B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a very probable diagnosis of heart failure. A 12-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

The nurse is caring for a patient who is receiving IV furosemide and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. Weight loss of 2 lb in 24 hours b. Hourly urine output greater than 60 mL c. Reduced dyspnea with the head of bed at 30 degrees d. Patient denies experiencing chest pain or chest pressure

ANS: C Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data may also indicate that diuresis or improvement in cardiac output has occurred but are not specific to evaluating this patient's response.

The nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill. Which assessment finding requires the most rapid action by the nurse? a. Patient reports feeling tired b. Sinus tachycardia at a rate of 110 beats/min c. Inversion of T waves on the electrocardiogram d. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg

ANS: C ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate O2 delivery and that the exercise test should be stopped immediately. Increases in BP and heart rate are normal responses to aerobic exercise. Feeling tired is also normal as the intensity of exercise increases during the stress testing.

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient? a. "Heparin enhances platelet aggregation at the plaque site." b. "Heparin decreases the size of the coronary artery plaque." c. "Heparin prevents the development of new clots in the coronary arteries." d. "Heparin dissolves clots that are blocking blood flow in the coronary arteries."

ANS: C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be important to report to the health care provider before the MRI? a. The patient has an allergy to shellfish. b. The patient has a history of atherosclerosis. c. The patient has a permanent cardiac pacemaker. d. The patient took the prescribed heart medications today.

ANS: C MRI is discouraged in those with older model pacemakers and ICDs because the magnets can change the function of the devices. However, when there is a strong clinical need and the benefits outweigh the risks, MRI can be done at centers experienced in this procedure. It will be important to determine the type of pacemaker. Many newer models of pacemakers and ICDs are approved for use with MRI. The other information does not affect whether the patient can have an MRI. There is no iodine-based contrast administered for an MRI, so a shellfish allergy would not affect the plans. A history of atherosclerosis or recent use of heart medications would not affect the process of the MRI.

Which data indicates to the nurse that the patient with stable angina is experiencing a side effect of metoprolol? a. Patient is restless and agitated. b. Patient reports feeling anxious. c. Blood pressure is 90/54 mm Hg. d. Heart monitor shows normal sinus rhythm.

ANS: C Patients taking -adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. Normal sinus rhythm is a normal and expected heart rhythm.

Diltiazem is prescribed for a patient newly diagnosed with Prinzmetal's (variant) angina. Which action of diltiazem is accurate for the nurse to include in the teaching plan? a. Reduces heart palpitations. b. Prevents coronary artery plaque. c. Decreases coronary artery spasms. d. Increases contractile force of the heart.

ANS: C Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and -adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand.

An older adult patient who has just arrived in the emergency department has a pulse deficit of 46 beats. Which intervention would the nurse anticipate for this patient? a. Cardiac catheterization b. Hourly blood pressure checks c. Electrocardiographic monitoring d. Emergent synchronized cardioversion

ANS: C Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which patient problem is the priority? a. Acute pain b. Deficient knowledge c. Impaired cardiac function d. Health maintenance alteration

ANS: C The hypotension and tachycardia indicate decreased cardiac output and shock from the impaired function of the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate? a. Jugular vein atherosclerosis b. Incompetent jugular vein valves c. Increased ventricular filling pressure d. Decreased intravascular fluid volume

ANS: C The jugular veins empty into the superior vena cava and then into the right atrium and ventricle, so JVD with the patient sitting at a 45-degree angle reflects increased atrial and ventricular pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

The nurse reviews information shown in the accompanying figure from the medical records of a 43-year-old patient. Which risk factor modification for coronary artery disease would the nurse include in patient teaching? a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Cardiac risk associated with previous tobacco use

ANS: C The patient has an elevated low-density lipoprotein cholesterol and low high-density lipoprotein cholesterol, which will increase the risk of coronary artery disease. The patient's waist circumference and body mass index indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines.

Which electrocardiographic (ECG) change by a patient with chest pain is most important for the nurse to report rapidly to the health care provider? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

ANS: C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction. Immediate therapy with percutaneous coronary intervention or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy but not as rapidly.

A transesophageal echocardiogram (TEE) is planned for a patient hospitalized with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first? a. Start an IV line. b. Start O2 per nasal cannula. c. Place the patient on NPO status. d. Give lorazepam (Ativan) 1 mg IV.

ANS: C The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds. d. Ask about the patient's allergies.

ANS: C This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) may be occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat. Which follow-up action would the nurse take? a. Encourage the patient to drink more liquids. b. Assess the apical and radial pulse for a pulse deficit. c. Observe the neck with the patient elevated 45 degrees. d. Have the patient bear down to perform the Valsalva maneuver.

ANS: C When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. JVD but is not confirmed based on the data given. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. More fluids will further increase any fluid overload.

Which foods would the nurse recommend limiting for a patient on a 2000-mg sodium diet? a. Chicken and eggs b. Canned and frozen fruits c. Yogurt and milk products d. Fresh or frozen vegetables

ANS: C Yogurt and milk products (e.g., cheese) naturally contain a significant amount of sodium, and the intake of these would be limited for patients on a diet that limits sodium to 2000 mg daily. The other foods listed have minimal levels of sodium and can be eaten without restriction.

Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. Which medication topic would the nurse anticipate including in discharge teaching? a. Calcium channel blocker b. Selective SA node inhibitor c. Digoxin and potassium therapy regimen d. Angiotensin-converting enzyme (ACE) inhibitor

ANS: D ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other drugs such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. Ivabradine would likely be used for a patient with HF who has symptoms despite optimal doses of other medications.

After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient would the nurse assess first? a. A 39-year-old patient with pericarditis who is complaining of sharp, stabbing chest pain b. A 56-year-old patient with variant angina who is scheduled to receive nifedipine (Procardia) c. A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge d. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)

ANS: D After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.

Which statement made by a patient with coronary artery disease indicates that further diet teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."

ANS: D Although only 30% of the daily calories should come from fats, most of the fat in the diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the diet. The other patient comments indicate a good understanding of the recommended diet.

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. Which data would indicate to the nurse that the drug is effective? a. Decreased blood pressure and heart rate b. Improvement in the strength of the distal pulses c. Fewer complaints of having cold hands and feet d. Participation in daily activities without chest pain

ANS: D Because the drug is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective -adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.

Which patient statement would help the nurse confirm the previous diagnosis of chronic stable angina? a. "The pain wakes me up at night." b. "The pain is level 3 to 5 (0 to 10 scale)." c. "The pain has gotten worse over the last week." d. "The pain goes away with a nitroglycerin tablet."

ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

A patient is being treated for heart failure. Which laboratory test result will the nurse review to determine the effects of the treatment? a. Troponin b. Homocysteine (Hcy) c. Low-density lipoprotein (LDL) d. B-type natriuretic peptide (BNP)

ANS: D Levels of BNP are a marker for heart failure. The other laboratory results would assess for myocardial infarction (troponin) or the risk for coronary artery disease (Hcy and LDL).

Which statement by a patient newly diagnosed with heart failure indicates to the nurse that teaching was effective? a. "I will take furosemide (Lasix) every day just before bedtime." b. "I will use the nitroglycerin patch whenever I have chest pain." c. "I will use an additional pillow if I am short of breath at night." d. "I will call the clinic if my weight goes up 3 pounds in a week."

ANS: D Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 lb in 2 days or 3 to 5 lb in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as needed" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops rather than just compensating by further elevating the head of the bed.

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective? a. "I can expect nausea as a side effect of nitroglycerin." b. "I should only take nitroglycerin when I have chest pain." c. "Nitroglycerin helps prevent a clot by blocking blood flow to my heart." d. "I will call an ambulance if I have pain 5 minutes after taking nitroglycerin."

ANS: D The emergency response system (ERS) should be activated when chest pain or other symptoms are the same or worse 5 minutes after taking a sublingual nitroglycerin tablets. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

A patient will be evaluated for rhythm disturbances with a Holter monitor. Which instruction would the nurse provide? a. Connect the recorder to a computer once daily. b. Exercise more than usual while the monitor is in place. c. Remove the electrodes when taking a shower or tub bath. d. Keep a diary of daily activities while the monitor is worn.

ANS: D The patient is taught to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed.

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? a. 2+ bilateral pedal edema b. Heart rate of 52 beats/min c. Report of increased fatigue d. Blood pressure 88/42 mm Hg

ANS: D The patient's blood pressure indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of -adrenergic blockade, though it may need to be monitored. -Adrenergic blockade initially will worsen symptoms of heart failure in many patients and patients would be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

While doing the hospital admission assessment for a slender older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action would the nurse take? a. Teach the patient about aneurysms. b. Notify the hospital rapid response team c. Instruct the patient to remain on bed rest. d. Document the finding in the patient record.

ANS: D Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse would simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.

A patient with left-sided heart failure is prescribed O2 at 4L/min per nasal canula, furosemide, spironolactone and enalapril. Which assessment should the nurse complete to best evaluate the patient's response to these drugs?

Auscultate lung sounds

A patient is scheduled for a cardiac catheterization with coronary angiography. What information would the nurse provide before the procedure? a. It will be important not to move at all during the procedure. b. A flushed feeling is common when the contrast dye is injected. c. Monitored anesthesia care will be provided during the procedure. d. Arterial pressure monitoring will be needed for 24 hours after the test.

B A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.

What is Prinzmetal's (variant) angina?

Chest pain caused by spasm of major coronary arteries.

What is unstable Angina?

Chest pain that increases with occurrence, severity and duration over time at rest or with exercise

Fifteen minutes after the oxygen is replaced and he has rested, the patient denies being short of breath. You obtain an oxygen saturation and it is 96%. Based on this result, what should you do next.

Continue the assessment because 96% is acceptable.

What are common side effects from Nitroglycerin?

Headache Dizziness Flushing, Orthostatic hypertension

What is chronic stable angina?

Intermittent chest pain that occurs over a long period with similar pattern of onset, duration and intensity of symptoms.

What is silent ischemia

Ischemia that occurs in the absence of any subjective symptoms Same prognosis as ischemia with pain.

What is ejection fracture (EF)?

It is the amount of blood pumped out of LV with next systole

The home care nurse visits a patient with chronic heart failure who is taking digoxin and furosemide. The patient reports nausea and vomiting. Which action is most appropriate for the nurse to take?

Notify the health care provider immediately.

a client came to the hospital 2 days ago for recurrent exacerbation of HF. He has IV access in his left forearm and is on O2 at 2L per nasal canula. When you assess the patient, he is sitting on the side of the bed and appears to be short of breath after returning from bathroom. He is sweating and his nasal canula is laying on the bedside table. Which action should you take first?

Replace the oxygen

What is Heart Failure?

Syndrome resulting in insufficient blood supply/oxygen to tissues and organs. Decreased cardiac output leads to decreased tissue perfusion.

What is the clinical manifestation of right-sided heart failure?

Systemic congestion

What are three types of serum lipids tested for cardiac disorders?

Triglycerides Cholesterol Phospholipids

how long is the duration of pain with chronic stable angina?

a few minutes and subsides when precipitating factor is resolved.

What is the significance of increased BNP levels

increased levels of BNP levels signify heart failure

What can be the onset of chronic stable angina?

physical exertion stress emotional upset

How long can troponin levels be detected for?

up to 10-14 days

When does troponin levels rise?

within 4-6 hours