Chapter 17: Drug Therapy for Heart Failure

ANS: B The actions of diuretic drugs help heart failure in several ways. They can relax blood vessels and lower blood pressure so that less effort is needed for the heart contraction to move blood into the general circulation. Removing extra fluid from the circulation also can reduce blood pressure. In addition, some diuretics work on the heart muscle itself.

A patient asks you how a prescribed diuretic can help heart failure. What is your best response? a. "Urinating more prevents heart failure from damaging your kidneys." b. "Diuretics reduce blood pressure so your heart won't have to work as hard." c. "Taking a diuretic reduces salt levels so you don't have to limit your intake of salty foods." d. "The diuretic counteracts the side effects of the other drugs prescribed for your heart failure."

ANS: D Digoxin is a cardiac glycoside drug that works on the muscle fiber of the heart to crease the force of each contraction. It also slows down the heart rate. These actions help to improve cardiac output.

A patient asks you how prescribed digoxin (Lanoxin) will help improve heart failure. What is your best response? a. "It dilates your arteries and decreases your blood pressure." b. "It directly perfuses your kidneys which decreases your fluid volume and blood pressure." c. "It increases your heart rate which will result in improved cardiac output." d. "It increases the force of heart contractions and slows down the heart rate to improve cardiac output."

ANS: A, C, D, E Sublingual or buccal nitroglycerin should not be swallowed because the liver destroys most of the drug and makes it ineffective. The drug should be kept in place until it dissolved. Patients should not drink or eat until the tablet is dissolved. A tingling sensation as the tablet dissolves indicates that the drug is potent and any time a patient's chest pain persists after using one tablet, the prescriber should be notified.

A patient has been prescribed sublingual nitroglycerin. Which key points will you teach the patient about this drug? (select all that apply) a. Keep the tablet in place until it is dissolved. b. Swallow the tablet with a full glass of water. c. A tingling sensation means that the drug is potent. d. Do not eat anything until after the tablet is dissolved. e. Call your prescriber if chest pain persists after one tablet.

ANS: 0.6 Want 0.03 mg, Have 0.05 mg/1 mL. Cancel mg; 0.05X = 0.03; X = 0.6. 0.6 1 mL = 0.6 mL.

A patient is prescribed digoxin (Lanoxin) 0.03 mg as a liquid dose. The drug on hand is digoxin 0.05 mg/mL. How many milliliters do you give?

ANS: A The two drugs, Inocor and Primacor, are not the same, although both are positive inotropes. Their dosages and infusion rates are very different. The pharmacy has sent up the wrong drug or has labeled the infusion bag incorrectly. Either way, you must stop the existing infusion and clarify all of this with the prescriber first and then the pharmacy.

A patient is prescribed inamrinone (Inocor) by continuous intravenous infusion. When you make rounds and assess the patient, the intravenous bag infusing is labeled (Primacor). What should you do? a. Stop the infusion and notify the prescriber. b. Assess the infusion site for a blood return. c. Document the infusion and site conditions as the only action. d. Slow the infusion rate because Primacor is more potent than Inocor.

ANS: A Isosorbide dilates blood vessels to allow better blood flow to the heart muscle. However, blood vessels are dilated in many body areas. When blood vessels in the brain or head are dilated, headaches can occur.

A patient is prescribed isosorbide (Isordil). Which condition will you teach the patient is an expected side effect of this drug? a. Frequent headaches b. Cold hands and feet c. Change in urine color d. Distaste for sweet foods or drinks

ANS: A High blood levels of magnesium interfere with muscle contraction, causing muscle weakness. Breathing is dependent on good contraction of respiratory muscles. Shallow and slow respirations are a serious manifestation of excess blood magnesium levels.

A patient is receiving magnesium by intravenous infusion. Which finding indicates that the patient's blood magnesium level may be too high? a. Respirations are 10 per minute and shallow. b. Heart rate is 66 beats/min and regular. c. The patient reports difficulty staying asleep. d. Episodes of diarrhea.

ANS: A, C, E Nesiritide is given by the IV route, so you should always ensure that the IV line is patent. Heart and respiratory rate should always be assessed before giving this drug. The heart rate should be between 60 and 100 beats/min and the respiratory rate should be between 12 and 20 breaths/min.

A patient is to receive nesiritide (Natrecor). Which patient assessments must be checked before giving this drug? (select all that apply) a. Heart rate b. Swallowing reflex c. IV line for patency d. Oral intake e. Respiratory rate factors

ANS: D Dobutamine is a positive inotropic drug. Side effects include improved urine output and increased blood pressure. Facial flushing is common but not serious. Chest pain indicates the heart is working too hard, which may be related to the dosage level. You should slow the drip rate and immediately notify the prescriber.

A patient receiving dobutamine (Dobutrex) at 180 mcg/min is having all of the following physiologic responses. Which response indicates that the drip rate may be too high? a. Systolic blood pressure increase from 106 to 122 mm Hg b. Hourly urine output of 100 mL c. Facial flushing d. Chest pain

ANS: B Serum potassium level affects the activity of digoxin. A value of 2.8 is low (hypokalemia). Any abnormal potassium value (high or low) requires the prescriber to change the digoxin dosage. In addition, action is needed to bring this critical electrolyte value back to its normal range. Although the other laboratory values are slightly abnormal, none are critically abnormal or likely to have an effect on digoxin activity.

A patient taking digoxin (Lanoxin) has all of the following laboratory blood values. Which value do you report to the prescriber before administering the next dose of digoxin? a. Sodium 133 mEq/L b. Potassium 2.8 mEq/L c. Blood urea nitrogen 9 mg/dL d. White blood cell count 11,000 cells/mm3

ANS: B Many conditions can cause a cough, but a dry, nonproductive cough is the most common side effect of lisinopril and all other ACE inhibitors. Coughs associated with pulmonary infections or worsening of heart failure are usually productive. After assessing the patient's issues with the cough, if the patient is uncomfortable or if the cough interferes with sleeping and other activities, report these problems to the prescriber.

A patient taking lisinopril (Zestril) for heart failure reports a nagging, nonproductive cough. What is your best first action? a. Ask the patient whether he or she has received the annual influenza vaccination. b. Ask the patient how much the cough is interfering with sleep or other activities. c. Document the report as the only action. d. Notify the prescriber immediately.

ANS: 0.8 1 kg = 2.2 lb. The patient's weight in kilogram is 117.72 kg (259/2.2). The correct dose is 2 mcg 117.72 kg, 235.4 mcg. 1 mL of the drug = 0.3 mg (divide 1.5 mg by 5 to get the concentration per mL) or 300 mcg/mL (1 mg = 1000 mcg). Divide 235.4 mcg by 300 mcg for the correct volume to prepare, which is 0.78 mL, round up to 0.8 mL.

A patient who weighs 259 lb is prescribed to receive nesiritide (Natrecor) 2 mcg/kg as an intravenous bolus. The drug available is 1.5 mg/5 mL. How many milliliters of the drug will you prepare to make the correct dose?

ANS: B Spironolactone, when used in low doses, blocks the action of aldosterone, which causes the body to lose salt and water. Furosemide works in the loop of Henle to decrease reabsorption of salt and water. Spironolactone is usually prescribed with another diuretic to decrease the volume of fluid in the blood vessels, which reduces the workload of the heart. Additionally when used together, these drugs help the body maintain a more normal blood potassium level.

A patient with heart failure asks why two diuretic drugs, furosemide (Lasix) and spironolactone (Aldactone), have been prescribed. What is your best response? a. "Your prescriber wants you to lose fluids and that's why you are taking two diuretics." b. "Each of these diuretics works in a different way to decrease workload on your heart." c. "Using two diuretics will double the amount of fluid you lose to decrease the work your heart must do." d. "Let me contact your prescriber because patients usually do not take two diuretics at the same time."

ANS: B Decreasing blood pressure helps improve the heart's action as a pump and decreases the heart's workload. Diuretics are used to decrease blood volume. Enalopril is an angiotensin-converting enzyme (ACE) inhibitor that interferes with the transition of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor that causes increased blood pressure and increased workload for the heart.

A patient with heart failure asks you why the antihypertensive drug enalapril (Vasotec) has been prescribed. What is your best response? a. "Hypertension is the most common cause of heart failure." b. "Lowering your blood pressure will allow your heart to pump more easily." c. "This drug will decrease the amount of blood your heart has to pump, leading to less work for your hart." d. "Enalapril will cause your heart to reestablish its normal electrical functions so that it works more effectively as a pump."

ANS: C The usual IV dose of furosemide ranges between 10 and 80 mg. A dose of 400 mg is very large. You must verify the correct drug dose before administering it.

A patient with heart failure is prescribed a one-time dose of furosemide (Lasix) 400 mg by intravenous (IV) push immediately. What is the best action? a. Contact the prescriber and request that the dose be changed from IV push to IV piggyback. b. Give the dose by IV push over a 10-minute period of time. c. Hold the dose and notify the prescriber immediately. d. Start an IV and administer the drug as prescribed.

ANS: C Nausea, blurry vision, and heart rate or rhythm changes are signs of digoxin overdose. The dose should be held and the prescriber notified. Most likely you will also be asked to obtain a blood sample to measure the digoxin level. Digoxin has a very narrow therapeutic range (0.8 to 2 ng/mL) and this level should be checked whenever a patient shows any signs of toxicity. Symptoms usually resolve when the drug is held and the body eliminates it.

A patient with heart failure is prescribed digoxin (Lanoxin). The patient reports nausea, blurry vision, and feeling like the heart is skipping beats. What is your best action? a. Administer the scheduled dose because it will correct these heart failure symptoms. b. Assess the patient's heart rate and then administer the scheduled dose. c. Hold the dose and notify the prescriber immediately. d. Place the patient on complete bed rest.

ANS: B When prescribed to treat heart failure, only the sustained-release form of metoprolol is used. Metoprolol (Toprol XL) is the sustained-release form of the drug, whereas metoprolol (Lopressor) is not.

A patient with heart failure is prescribed metoprolol (Toprol XL) 25 mg daily. The pharmacy sends metoprolol (Lopressor) 25 mg. What is your best action? a. Give the dose as provided because the drugs are the same. b. Ask the pharmacy to send the drug as ordered. c. Contact the prescriber for clarification. d. Check the patient's heart rate before giving the dose.

ANS: C Beta blockers and ACE inhibitors are often used together to treat heart failure. Beta blockers block the effects of epinephrine on the heart resulting in deceased heart rate and force of contraction, thus decreased blood pressure. You should notify the prescriber if the heart rate is less than 60 per minute.

A patient with heart failure is prescribed oral captopril (Capoten) and carvedilol (Coreg). The heart rate after giving these drugs is decreased from 84 per minute to 68 per minute. What is your best action? a. Hold the next dose. b. Immediately notify the prescriber. c. Document the finding as the only action. d. Schedule the captopril and carvedilol to be given at different times.

ANS: A Patients receiving dobutamine at home should be taught the signs and symptoms of IV lines that are no longer patent or have developed infection (e.g., burning, pain, redness, swelling, warmth at the site). Patients should be instructed to report these signs immediately to the prescriber or home health nurse.

A patient with heart failure is receiving dobutamine (Dobutrex) intravenously at home. Which sign or symptom should the patient and family be instructed to report to the prescriber immediately? a. Burning or pain at the intravenous (IV) site b. Heart rate between 60 and 70 beats/min c. Urine output of 1600 mL over 24 hours d. Brief episode of shortness of breath

ANS: D Patient weight gain and increased shortness of breath are signs of worsening heart failure. The prescriber should be notified because the plan of care may need to be modified. If the patient is taking a diuretic, it is likely that the dose may be increased.

A patient with heart failure reports a 5 lb weight gain during the past week and episodes of feeling more short of breath. What is your best response? a. "These changes are to be expected because you have heart failure." b. "You will probably need a decreased dose of your diuretic drug." c. "I will ask the dietitian to discuss a weight loss diet with you." d. "Your prescriber must be notified because your heart failure is getting worse."

ANS: D Common side effects of nitroglycerin ointment include hypotension and headaches. When this drug is administered, if a person's skin comes into contact with the drug as it is squeezed onto the special lined paper, these side effects may develop. Wearing gloves prevents skin contact with the drug and decreases the risk for side effects.

A patient with severe heart failure is discharged with a prescription for nitroglycerin ointment. What technique do you teach the patient's spouse to use to avoid experiencing side effects when applying this drug? a. Squeeze the ointment onto the special paper. b. Cleanse the skin before applying the drug. c. Rotate the drug application skin sites. d. Wear a pair of disposable gloves.

ANS: B Antihypertensive drugs decrease blood pressure and increase a patient's risk for dizziness, light-headedness, and hypotension. After giving the first dose of any antihypertensive drug, you should be sure that the call light is within easy reach and instruct the patient to call for assistance when getting out of bed. A wheelchair is not necessary and standards of practice state that all four side rails should not be raised because there is a risk for falls if the patient tries to get out of bed alone.

After giving the first dose of any antihypertensive drug for heart failure, what action must be taken for a hospitalized patient's safety? a. Recheck the drug order for accuracy. b. Ensure that the call light is within reach. c. Place a wheelchair in the patient's room. d. Raise all four side rails on the patient's bed.

ANS: C The usual dosage of digoxin is 0.125 to 0.25 mg/day. The order is for 10 to 20 times the normal dose. If this dose is given the results would be adverse effects of even death. The other drug dosages are within the correct ranges.

For which drug order would you contact the prescriber to verify it is correct? a. Furosemide (Lasix) 40 mg orally each day b. Fosinopril (Monopril) 20 mg orally each day c. Digoxin (Lanoxin) 2.5 mg orally each day d. Amiloride (Midamor) 5 mg orally each day

ANS: D Nesiritide (Natrecor) is human B-type natriuretic peptide, which is a hormone that is produced by the heart ventricles and a synthetic drug. The actions of this drug include increased water elimination and blood vessel dilation. Both are helpful when treating a patient with heart failure. This drug is given by the IV route and helps the body get rid of extra salt and water, thus lowering blood pressure.

How do natriuretic peptides work to help improve heart failure? a. Increasing preload b. Decreasing preload c. Decreasing water loss and raising blood pressure d. Increasing water loss and lowering blood pressure

ANS: C Hydralazine is a vasodilator. Vasodilators are a class of drugs that act directly on the peripheral arteries to cause them to dilate (widen). This leads to lowering of blood pressure and decreases the workload of the heart.

How does hydralazine (Apresoline) help improve heart failure? a. By directly stimulating the right heart muscle to increase the strength of heart muscle contraction b. By directly stimulating the left heart muscle to increase the strength of heart muscle contraction c. By directly relaxing blood vessel muscles and decreasing afterload d. By directly constricting blood vessel muscles and increasing afterload

ANS: C Sublingual means to place the drug under the tongue. Remind patients that sublingual nitroglycerin should be kept in place until dissolved.

How should sublingual nitroglycerin tablets for heart failure be taken? a. On a full stomach b. On an empty stomach c. Dissolved under the tongue d. Placed under a patch on the chest

ANS: 3 Want 30 mg, Have 10 mg/tablet. 30 mg/X tablets : 10 mg/1 tablet. Cancel mg; 30/10 = 3 tablets.

The patient is prescribed potassium (K-Dur) tablets 30 mg orally each morning. You have potassium (K-Dur) in 10 mg tablets. How many tablets will you give for each dose?

ANS: B Afterload is the pressure in the aorta that the left ventricle must overcome before blood can move from it into the aorta. Mean arterial pressure (MAP) is also the pressure that the left ventricle must overcome to move blood from the left ventricle into the aorta during contraction (afterload). Afterload increases because of increased peripheral resistance usually as a result of high blood pressure.

What does the term "afterload" mean? a. The amount of blood entering the left ventricle that must be pumped out of the heart b. The peripheral resistance of the arterial system, including mean arterial pressure c. The ability of the living muscle fibers of the heart to contract and pump blood d. The percentage of blood pumped out of the heart with each heartbeat

ANS: A Common side effects of hydralazine include tachycardia and salt retention.

What is a common side effect of hydralazine (Apresoline) therapy for heart failure? a. Tachycardia b. High blood pressure c. Constipation d. Difficulty sleeping

ANS: D The muscle of the left ventricle becomes overstretched. When any muscle is overstretched, its contraction is weaker. When the muscles of the left ventricle are overstretched or flabby and the contraction is weak, too much blood remains in the left ventricle, and more blood arriving from the left atrium is added to it. This overstretches the muscle more and continues to weaken contractions, leading to heart failure.

What is the main physiological problem in most types of heart failure? a. Overstretching of the right ventricle so that too much blood leaves the heart b. Overstretching of the right ventricle so that too little blood leaves the heart c. Overstretching of the left ventricle so that too much blood leaves the heart d. Overstretching of the left ventricle so that too little blood leaves the heart

ANS: A Cardiac glycosides are a class of drugs that improve heart failure by slowing down a heart rate that is too fast, allowing more time for the left ventricle to fill. They also work on the muscle fibers in the heart and increase the force of each heartbeat (contractility).

What is the mechanism of action for cardiac glycosides? a. Slowing the heart rate and increasing the force of the heart muscle contraction b. Increasing the heart rate and decreasing the force of the heart muscle contraction c. Directly relaxing blood vessel muscles and decreasing afterload d. Directly constricting blood vessel muscles and increasing afterload

ANS: A Most heart failure is caused by hypertension. Other causes of heart failure include myocardial infarction, coronary artery disease, cardiomyopathy, substance abuse (alcohol and illicit or prescribed drugs), heart valve disease, congenital defects, cardiac infections and inflammations, and conditions that increase cardiac output and energy demands such as sepsis.

What is the most common cause of heart failure? a. High blood pressure b. Low blood pressure c. Defective heart valves d. Defective coronary arteries

ANS: B The most common side effects of digoxin (Lanoxin), a cardiac glycoside, are heart rhythm disturbances that are related to digoxin toxicity. Other common side effects to watch for include fatigue, bradycardia (slow heart rate less than 60 beats/min), anorexia (loss of appetite), nausea, and vomiting.

What is the most common side effect of cardiac glycoside drugs for heart failure therapy? a. Abdominal cramping and constipation b. Heart rhythm disturbances c. High blood pressure d. Skin rashes

ANS: A Although all the actions are important, the most important is to ensure that the pulse rate is between 60 and 100 beats/min and is regular before administering digoxin or any other cardiac glycoside. For an irregular heart rate or one that is outside of this range, the dose must be held and the prescriber notified immediately.

What is the most important action for you to teach a patient to perform before taking his or her daily dose of digoxin (Lanoxin)? a. Check the pulse for a full 60 seconds. b. Look for edema in your ankles. c. Notify the prescriber for any heart palpitations. d. Take the drug at exactly the same time every day.

ANS: C Blood potassium levels have a very narrow range of normal. When intravenous potassium is administered at too high a dose or too rapidly, life-threatening cardiac rhythm problems develop and death is possible. Always check an intravenous potassium dose with another health care professional and never administer it either by intravenous push or as a bolus.

What is the most important reason intravenous potassium is considered a high alert drug? a. When intravenous potassium is administered at too low a dose its mechanism of action is greatly reduced. b. Intravenous potassium is a highly irritating solution and can cause significant pain or burning at the infusion site. c. Administering too much intravenous potassium or administering it too quickly may cause life-threatening problems. d. Excessive blood potassium levels can lead to nausea, vomiting, severe diarrhea, abdominal cramping, and other intestinal problems.

ANS: B Common side effects of potassium include nausea, vomiting, diarrhea, gas, and abdominal discomfort. Taking the drug with food or right after meals with a full glass of water or fruit juice will decrease or prevent these side effects. A patient should never take a double dose of a prescribed drug. Most salt substitutes are made by replacing sodium with potassium. Use of salt substitutes or eating excessive amounts of foods that are high in potassium while taking a potassium supplement increases the risk of hyperkalemia (high blood potassium).

What should you teach a patient who has been prescribed potassium (K-Dur) tablets? a. "If you miss a dose, double your next dose to keep your blood level of potassium normal." b. "Take your potassium with food or a full glass or water to avoid nausea/vomiting." c. "Be sure to use salt substitutes instead of salt so that your body will not retain water." d. "Eat lots of foods that are high in potassium such as bananas, spinach, broccoli, and sweet potatoes."

ANS: A Vasodilators act directly on the peripheral arteries, causing them to dilate, which leads to decreased blood pressure and workload on the heart. When patients cannot take ACE inhibitors or angiotensin II receptor blockers, vasodilators are often prescribed.

When are vasodilator drugs usually prescribed for heart failure? a. When angiotensin-converting enzyme (ACE) inhibitors cannot be taken b. When venous dilation is also needed c. When beta blockers are also being taken d. When heart failure is improving

ANS: A, C, E The sympathetic nervous system releases the catecholamine hormones epinephrine and norepinephrine, which act on the heart in two ways. First they increase the heart rate, and second they increase the power of the heart muscle fibers to contract so that the heart pumps more forcefully. These actions increase cardiac output.

Which are sympathetic nervous system compensatory mechanisms of the body for heart failure? (select all that apply) a. Increased heart rate b. Decreased respiratory rate c. Increased contractility d. Decreased body temperature e. Increased cardiac output f. Decreased cardiac output

ANS: D Ankle swelling is associated with heart failure, although other conditions also can cause it. If this is a new symptom or is occurring even when the patient is not spending a lot of time sitting or standing, the nurse should assess the patient for other symptoms of heart failure. Although the blood pressure is not high, the pulse pressure is wide which does not indicate failure. A pounding headache is most associated with elevated blood pressure. Foul-smelling urine is associated with urinary tract infection.

Which condition alerts you to assess a patient for worsening heart failure? a. Blood pressure of 106/40 mm Hg b. Pounding headache c. Foul urine odor d. Ankle swelling

ANS: D Dobutamine (Dobutrex) is a positive inotrope. This drug is a heart pump drug that makes the heart muscle contract more forcefully. It also relaxes blood vessels so blood can flow better.

Which drug for heart failure is a common positive inotrope? a. Amiloride (Midamor) b. Nesiritide (Natrecor) c. Captopril (Capoten) d. Dobutamine (Dobutrex)

ANS: B, C, E Lifestyle changes that are important in treating heart failure include weight loss, smoking cessation, and a low-salt and low-fat diet. A fluid restriction of 1000 mL can result in decreased perfusion of the kidneys. Patients with heart failure may not be able to tolerate an aerobic exercise program.

Which lifestyle changes should you suggest to a patient with heart failure? (select all that apply) a. Fluid restriction of 1000 mL/day b. Weight loss program c. Smoking cessation program d. Aerobic exercise program e. Low-salt, low-fat diet

ANS: D The previous patch must be removed (and the area wiped clean of drug) before applying a new patch (to a different site) to prevent leftover drug from contributing to a drug overdose. Applying the patch directly over the heart does not increase the speed of drug action on the heart.

Which precaution should you stress when teaching a patient about a prescribed nitroglycerin transdermal patch? a. "If a patch comes loose, tape it tightly to the skin with several layers of tape." b. "Do not remove old patches, just let them fall off over time." c. "Take care to apply the patches directly over your heart." d. "Remove the old patch before applying the new patch."

ANS: A Antihypertensive drugs lower blood pressure, placing the patient at increased risk for dizziness and hypotension. Changing positions slowly gives the body time to adjust, preventing dizziness and falls. The patient can get up at home without assistance if he or she changes positions slowly. Some, but not all, over-the-counter drugs may not be safe with these drugs. You should teach the patient to always consult with the prescriber before taking an over-the-counter drug.

Which safety precaution should be taught to a patient going home on any antihypertensive drug for heart failure? a. Always change positions slowly. b. Never get up without assistance. c. Take the drug in the evening before bedtime. d. Avoid all over-the-counter drugs while taking this drug.

ANS: B Drug therapy only improves heart function; drugs do not cure heart failure. Because the damage to the heart muscle is not reversible, the only real cure for heart failure is a heart transplant

Which statement about drug therapy for heart failure is true? a. The drugs work only directly on the heart muscle. b. Drug therapy improves heart function but does not cure heart failure. c. When heart function returns to normal, the drug therapy can be stopped. d. Drug therapy for heart failure does not work when the patient continues to smoke.

ANS: B Nitroglycerin ointment or patches lose their effectiveness when used continuously. The drug works much better when there is a "drug free" time during a 24-hour period. Usually the drug is removed at night when the patient has his or her longest sleeping period because the heart is less stressed during that time.

Which statement by a patient receiving nitroglycerin ointment indicates the need for additional teaching? a. "I will remove the previous dose before I put on the new dose." b. "I will reapply the dose every 4 hours around the clock." c. "I must avoid rubbing my skin when I put on a new dose." d. "I will put tape over the paper so that the dose stays in place."

ANS: C Heart failure can be improved with drug therapy but the underlying condition remains. When heart failure is a result of damage, it is not cured. Drug dosage needs may change to control heart failure, but usually the dosages only increase as time goes on.

Which statement made by a patient with heart failure indicates that more teaching is needed about the prescribed drug therapy? a. "I always try to take my heart failure drugs at the same time each day." b. "Now I am using a weekly pill dispenser to keep my drugs straight." c. "Now that my heart failure is cured I can cut back the drugs I take." d. "If I gain more than 3 lb in a week I will call my doctor."

ANS: D When the left ventricle fails, less blood is pumped out to the body and blood backs up into the pulmonary system causing signs of pulmonary congestion such as crackles and wheezes. Weight gain, peripheral swelling, and jugular vein distention are all signs of right ventricular failure.

Which symptom is commonly assessed when a patient has left ventricular heart failure? a. Weight gain b. Swelling in the legs c. Jugular vein distention d. Crackles in the lungs

ANS: D When the right ventricle contracts poorly, signs and symptoms of peripheral congestion occur (Box 17-2 in text) such as weight gain, swelling in the legs, jugular vein distention (Figure 17-4 in text), and increased blood pressure.

Which symptom occurs with only pure right-sided heart failure and does not occur with pure left-sided heart failure? a. Confusion b. Shortness of breath c. Decreased afterload d. Swelling in the ankles and legs

ANS: B Cardiac output is the movement of blood out of the heart and into general circulation. Preload is the amount of blood in the left ventricle before contraction. This volume stretches the muscle of the left ventricle to result in a better force of contraction. So, to a point, greater preload helps improve cardiac output. Afterload is the pressure in the aorta that must be overcome for blood to leave the left ventricle. When this pressure is lower, the heart does not have to work as hard to move blood out of the left ventricle into the aorta. So, greater preload and reduced afterload tend to improve cardiac output.

Which two factors are most likely to result in improved cardiac output? a. Greater preload; greater afterload b. Greater preload; reduced afterload c. Reduced preload; greater afterload d. Reduced preload; reduced afterload

ANS: A Hydralazine can be safely used for blood pressure control during pregnancy, but isosorbide and nitroglycerin may affect fetal circulation and should be used with caution during pregnancy. Minoxidil is a vasodilator that is not generally used in the treatment of heart failure.

Which vasodilator drug can be safely prescribed for a patient with heart failure during pregnancy? a. Hydralazine (Apresoline) b. Isosorbide (Isordil) c. Minoxidil (Lonitin) d. Nitroglycerin (Nitrostat)

ANS: C Movement of blood through the other chambers of the heart is against low pressure, and the distance is short. Blood leaving the left ventricle must move with enough force to first overcome pressure in the aorta, which is the highest in the entire circulatory system, and then move long distances throughout the entire body. Contraction of the muscles in the walls of the left ventricle is what provides the pressure to move blood forward into general circulation.

Why must the muscles of the left ventricle be the strongest ones in the heart? a. The mitral (bicuspid) valve is larger than the aortic valve. b. The left ventricle receives blood under high pressure from the pulmonary system. c. The pressure in the aorta is higher than the pressures elsewhere in the circulatory system. d. Blood in the left ventricle is oxygenated, making it thicker and harder to move than deoxygenated blood.

ANS: D Some drugs for heart failure also slow the heart rate. If the heart rate is slow before taking the drug, the drug can slow the heart rate so much that the patient cannot adequately perfuse and oxygenate his or her vital organs. Usually, if the heart rate is less than 60 beats/min, the prescriber is notified. The next dose may be held until the pulse rate returns to normal.

You prepare to administer a drug for heart failure to a patient. Which assessment finding do you report to the prescriber before administering the drug? a. Systolic blood pressure increase from 128 to 136 b. Urine output of 2100 mL in 24 hours c. Weight gain of 1 lb in 3 days d. Heart rate of 54 beats/min