Heart Failure

A70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed for her to continue at home. Which response by the nurse is accurate? A "The medication prevents blood clots from forming in your heart." B "The medication dissolves clots that develop in your coronary arteries." C "The medication reduces clotting by decreasing serum potassium levels." D "The medication increases your heart rate so that clots do not form in your heart."

A "The medication prevents blood clots from forming in your heart." Chronic heart failure causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors.

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

A Administer ordered morphine sulfate. B Position patient in a semi-Fowler's position. D Instruct patient on the use of relaxation techniques. E Use a calm, reassuring approach while talking to patient. Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

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)? A Left ventricular function is documented. B Controlling dysrhythmias will eliminate HF. C Prescription for digoxin (Lanoxin) at discharge D Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge E Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

A Left ventricular function is documented. D Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge E Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.

A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurse's priority action will be to a. give IV morphine sulfate 4 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase nitroglycerin (Tridil) infusion by 5 mcg/min. d. increase dopamine (Intropin) 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

Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)? a. How to take and record daily weight b. Importance of limiting aerobic exercise c. Date and time of follow-up appointment d. Symptoms indicating worsening heart failure e. Actions and side effects of prescribed medications

ANS: A, C, D, E The Joint Commission Core Measures state that patients should be taught about prescribed medications, follow-up appointments, weight monitoring, and actions to take for worsening symptoms. Patients with heart failure are encouraged to begin or continue aerobic exercises such as walking, while self-monitoring to avoid excessive fatigue

A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Assess the IV insertion site for signs of extravasation. b. Teach the patient the reasons for remaining on bed rest. c. Monitor the patient's blood pressure and heart rate every hour. d. Titrate the rate to keep the systolic blood pressure >90 mm Hg.

ANS: C An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, making adjustments to the drip rate for vasoactive medications, and monitoring for serious complications such as extravasation require RN level education and scope of practice

A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. "I will be sure to take the medication with food." b. "I will need to eat more potassium-rich foods in my diet." c. "I will call for help when I need to get up to use the bathroom." d. "I will expect to feel more short of breath for the next few days."

ANS: C Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of b-adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating

A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1 to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

ANS: C Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops. d. skip the digoxin if the pulse is below 60 beats/minute.

ANS: C Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that a. she will take furosemide (Lasix) every day at bedtime. b. the nitroglycerin patch is applied when any chest pain develops. c. she will call the clinic if her weight goes from 124 to 128 pounds in a week. d. an additional pillow can help her sleep if she is feeling short of breath at night.

ANS: C 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 pounds in 2 days or 3 to 5 pounds 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

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's priority action will be to a. have the patient recall the dietary intake for the last 3 days. b. ask the patient about the use of the prescribed medications. c. assess the patient for clinical manifestations of acute heart failure. d. teach the patient about the importance of restricting dietary sodium.

ANS: C The 5-pound 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 topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%? a. Need to begin an aerobic exercise program several times weekly b. Use of salt substitutes to replace table salt when cooking and at the table c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors d. Importance of making an annual appointment with the primary care provider

ANS: C The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually

While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a a. consult with a psychologist. b. transfer to a long-term care facility. c. referral to a home health care agency. d. arrangements for around-the-clock care.

ANS: C The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care

While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. jugular vein atherosclerosis. c. increased right atrial pressure. d. incompetent jugular vein valves.

ANS: C The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial 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

A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds. d. Assess the level of orientation.

ANS: C This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is 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 also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority

A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside, what should the nurse assess first? A Urine output B Heart rhythm C Breath sounds D Blood pressure

D Blood pressure The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas exchange.

Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? A Infection B Acute rejection C Immunosuppression D Cardiac vasculopathy

D Cardiac vasculopathy Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient's risk of an infection.

A nurse in a provider's office is monitoring serum electrolytes for 4 older adult clients who take digoxin(Lanoxin) & furosemide(Lasix). Which of the following electrolyte values puts a client at risk for dig toxicity? 1. Calcium 9.2 mg/dL 2. Calcium 10.3 mg/dL 3. Potassium 3.4 mEq/L 4. Potassium 4.8 mEq/L

3. Potassium 3.4 mEq/L

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

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

Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Titrate nesiritide slowly before stopping. d. Teach patient about home use of the drug.

ANS: A Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Because the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in a home setting

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 probable or very probable diagnosis of heart failure. A twelve-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

When caring for a client receiving triamterene (Dyrenium), the nurse places priority on which nursing intervention? Monitor electrolytes for hyperkalemia. Monitor electrolytes for hypernatremia. Monitor heart rate closely. Monitor blood pressure closely.

Monitor electrolytes for hyperkalemia. Rationale: Dyrenium is a potassium-sparing diuretic. The client should be monitored for signs of hyperkalemia. Hyponatremia, not hypernatremia may occur. BP and heart rate should be monitored, but are not priority with this drug.

20] Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? a. Increased blood pressure b. Increased urine output c. Decreased pain d. Decreased premature ventricular contractions

b. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias

A nurse is monitoring the digoxin level for a client who has been taking a daily dose of digoxin for 1 month. the digoxin level is 0.25 ng/mL. The nurse should notify the provider and anticipate which of the following: 1. An increase in the client's digoxin dose. 2. A decrease in the client's digoxin dose. 3. No change in the client's digoxin dose. 4. Dicontinuation of the client's digoxin dose.

1. An increase in the client's digoxin dose.

A nurse is providing teaching to a client who has a new prescription for digoxin (Lanoxin) Which of the following may indicate dig toxicity & should be reported to the provider? 1. Fatigue 2. constipation 3. Anorexia 4. Rash 5. Diplopia

1. Fatigue Not constipation but -- nausea, vomiting & diarrhea 3. Anorexia b/c GI disturbances 5. Diplopia -- visual changes , halo, yellow-tinged vision.

Lisinopril (Prinivil) is part of the treatment regimen for a client with HF. The nurse monitors the client for the development of which of teh following adverse effects of this drug? SELECT ALL THAT APPLY 1. Hyperkalemia 2.Hypocalcemia 3. Cough 4. Dizziness 5. Heartburn

1. Hyperkalemia 2.Hypocalcemia 3. Cough 4. Dizziness

A nurse is administering a dopamine infusion at a moderate dose to a client who has severe HF. Which of the following is an expected effect? 1. Lowered heart rate 2. Increased myocardial contractility 3. Decreased conduction through the AV node D. Vasoconstriction of the renal blood vessels

2. Increased myocardial contractility -- thus increasing CO

A nurse is caring for an older adult client who has a new prescription for digoxin and takes multiple other medications. concurrent use of which of the following medications places the client at risk for dig toxicity? 1. Phenytoin (Dilantin) 2. Verapamil (Calan) 3. Warfarin (Coumadin) 4. Aluminum hydroxide (Amphojel)

2. Verapamil (Calan) -- CCB, can increase digoxin levels. if used together dig dosage may need to be lowered.

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? A Reduce preload. B Decrease afterload. C Increase contractility. D Promote vasodilation.

A Reduce preload. Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.

A client with HF has an order for lisnopril (Prinivil, Zestril) Which of the following conditions in the client's history would lead a nurse to confirm the order with the provider? 1. A history of HT previously treated with diuretics. 2. A history of seasonal allergies currently treated with antihistamines. 3. A history of angioedema after taking enalapril (Vasotec) 4. A history of alcoholism, currently abstaining.

A history of angioedema after taking enalapril (Vasotec)

Patients with a heart transplantation are at risk for which complications in the first year after transplantation (select all that apply)? b. infection c. rejection e. sudden cardiac death

A variety of complications can occur after heart transplantation. In the first year after transplantation, the major causes of death are acute rejection and infection. Heart transplant recipients also are at risk for sudden cardiac death. Later, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are major causes of death.

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. A patient who is cool and clammy, with new-onset confusion and restlessness b. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. c. A patient who had dizziness after receiving the first dose of captopril (Capoten) d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

ANS: A The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L c. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache d. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough

ANS: B The patient's low potassium level increases the risk for digoxin toxicity and potentially fatal dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their medications, but their symptoms do not indicate potentially life-threatening complications

IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops a. ventricular ectopy. b. a dry, hacking cough. c. a systolic BP <90 mm Hg. d. a heart rate <50 beats/minute.

ANS: C Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy

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+ pedal edema b. Heart rate of 56 beats/minute c. Blood pressure (BP) of 88/42 mm Hg d. Complaints of fatigue

ANS: C The patient's BP indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of b-adrenergic blockade, but the rate of 56 is not unusual with â-adrenergic blocker therapy. b-Adrenergic blockade initially will worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs

When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. canned and frozen fruits. b. fresh or frozen vegetables. c. eggs and other high-protein foods. d. milk, yogurt, and other milk products.

ANS: D Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction

A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. What should this patient be taught to avoid? A High-potassium foods B Drugs to treat erectile dysfunction C Nonsteroidal antiinflammatory drugs D Over-the-counter H2 -receptor blockers

B Drugs to treat erectile dysfunction The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. High-potassium foods, NSAIDs, and H2-receptor blockers do not pose a risk in combination with nitrates.

A 54-year-old male 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? A Perform a bladder scan to assess for urinary retention. B Restrict the patient's oral fluid intake to 500 mL per day. C Assist the patient to a sitting position with arms on the overbed table. D Instruct the patient to use pursed-lip breathing until the dyspnea subsides.

C Assist the patient to a sitting position with arms on the overbed table. The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.

A client with congestive heart failure, CHF, is prescribed digoxin (Lanoxin) and furosemide (Lasix). Nursing interventions will include: (Select all that apply.) Encourage intake of water and fruit juices. Restrict intake of green, leafy vegetables. Checking apical pulse before administering medication. Monitor hemoglobin and hematocrit levels. Monitor serum electrolytes.

Checking apical pulse before administering medication. Monitor serum electrolytes. Rationale: Digoxin is a cardiac glycoside. which can slow heart rate, and an apical heart rate is checked prior to administration. Lasix is a loop diuretic used in treatment of CHF, which promotes not only water loss, but also loss of electrolytes. A low potassium level increases risk of digoxin toxicity. Fluids are often restricted with CHF. H and H level do not need to be checked, and green, leafy vegetables would not need to be restricted.

The client's serum digoxin level is 2.2 ng/dL and the heart rate is 120 and irregular. The nurse expects to administer which of the following drugs? Digoxin immune Fab (Digibind) Furosemide (Lasix) 60 mg I.V. Digoxin 0.5 mg bolus I.V. Potassium 40 mEq added to I.V. fluids

Digoxin immune Fab (Digibind) Rationale: Digibind binds and removes digoxin from the body and prevents toxic effects of digoxin overdose. A serum level of 2.2 is elevated, and the client is exhibiting signs of digoxin toxicity. The question does not indicate that the potassium level is low. Giving additional digoxin would exacerbate the toxicity. Giving Lasix may reduce potassium levels and contribute to increased toxicity.

Lisinopril (Prinivil) is part of the treatment regimen for a client with HF. The nurse monitors the client for which electrolyte imbalance of this drug? Hyponatremia Hyperkalemia Hypokalemia Hypernatremia

Hyperkalemia Rationale: ACE inhibitors block aldosterone secretion, which results in sodium loss and potassium retention. Hyperkalemia may occur, especially when the drug is taken concurrently with potassium-sparing diuretics.

A client is being started on lisinopril (Zestril). Nursing interventions during initial therapy with this medication must include Monitoring blood pressure. Monitoring intake and output. Monitoring EKG. Monitoring serum levels.

Monitoring blood pressure. Rationale: Lisinopril is an ACE inhibitor, which can cause severe hypotension with initial doses. The nurse should monitor the client closely for several hours.

The nurse reviews lab studies of a client receiving digoxin (Lanoxin). Intervention by the nurse is required if the results include a Serum sodium level of 140 mEq/L. Serum digoxin level of 1.2 ng/dL. Serum potassium level of 3.0 mEq/L. Hemoglobin 14.4 g/dL.

Serum potassium level of 3.0 mEq/L. Rationale: Normal serum potassium level is 3.5-5.0 mEq/L. Hypokalemia may predispose the client to digitalis toxicity. The other lab values are WNL.

The client is prescribed a beta-blocker as adjunct therapy to treatment of heart failure. The nurse recognizes that beta blockers act by Increasing contractility and cardiac output. Decreasing preload. Slowing the heart and decreasing afterload. Decreasing peripheral resistance

Slowing the heart and decreasing afterload. Rationale: Beta-blockers improve symptoms of HF by slowing heart rate and decreasing blood pressure. The decreased afterload causes decreased workload on the heart.

The nurse recognizes that primary manifestations of systolic failure include: a. decreased EF and increased PAWP

Systolic heart failure results in systolic failure in the left ventricle (LV). The LV loses its ability to generate enough pressure to eject blood forward through the aorta.

A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is: c. neurohormonal response

The following mechanisms in heart failure lead to inappropriate fluid retention and additional workload of the heart: activation of the renin-angiotensin-aldosterone system (RAAS) cascade and release of antidiuretic hormone from the posterior pituitary gland in response to low cerebral perfusion pressure that results from low cardiac output.

10] A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2mg of morphine sulfate given IV. The nurse should first: a. Administer the morphine b. Obtain a 12-lead ECG c. Obtain the blood work d. Order the chest radiograph

a. Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.

40] Which of the following is not a risk factor for the development of atherosclerosis? a. Family history of early heart attack b. Late onset of puberty c. Total blood cholesterol level greater than 220 mg/dL d. Elevated fasting blood glucose concentration

b. Late onset of puberty is not generally considered to be a risk factor for the development of atherosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette smoking, hypertension, high blood cholesterol level, male gender, diabetes mellitus, obesity, and physical inactivity

41] As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: a. Antispasmodic effects on the pericardium b. Causing an increased myocardial oxygen demand c. Vasodilation of peripheral vasculature d. Improved conductivity in the myocardium

c. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

36] The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet? a. Hamburger, salad, and milkshake b. Baked liver, green beans, and coffee c. Spaghetti with tomato sauce, salad, and coffee d. Fried chicken, green beans, and skim milk

c. Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

The nurse includes the definition of HF in the teaching plan for the client. An accurate description of the mechanism of HF is that [Hint] there is too much fluid in the heart. the heart cannot get oxygen. the heart is unable to pump effectively. there is too much fluid in the lungs.

the heart is unable to pump effectively.

During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to fatigue. b. disturbed body image related to weight gain. c. impaired skin integrity related to ankle edema. d. impaired gas exchange related to dyspnea on exertion.

ANS: A The patient's statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. Furosemide (Lasix) 60 mg b. Captopril (Capoten) 25 mg c. Digoxin (Lanoxin) 0.125 mg d. Carvedilol (Coreg) 3.125 mg

ANS: D Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other medications are appropriate for the patient with ADHF

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 should the nurse do next? A Withhold the daily dose until the following day. B Withhold the dose and report the potassium level. C Give the digoxin with a salty snack, such as crackers. D Give the digoxin with extra fluids to dilute the sodium level.

B Withhold the dose and report the potassium level The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

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

C Blood pressure Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.

The nurse prepares to administer digoxin (Lanoxin) 0.125 mg to an 82-year-old man admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication? A Prothrombin time B Urine specific gravity C Serum potassium level D Hemoglobin and hematocrit

C Serum potassium level Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity. Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit would not require holding the digoxin dose.

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

D Choose interventions to promote comfort and prevent suffering. The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not commonly used in the care of hospice patients.

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? A Muscle aches B Constipation C Pounding headache D Anorexia and nausea

D Anorexia and nausea Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

You are caring for a patient with ADHF who is receiving IV dobutamine (Dobutrex). You know that this drug is ordered because it (select all that apply): c. improves contractility e. works on the B1-receptors in the heart.

Dobutamine (Dobutrex) has a positive chronotropic effect and increases heart rate and improves contractility. It is a selective β-adrenergic agonist and works primarily on the β1-adrenergic receptors in the heart. It is frequently used in the short-term management of acute decompensated heart failure (ADHF).

The client is prescribed digoxin (Lanoxin) for treatment of HR. Which of the following statements by the client indicates the need for further teaching by the nurse? "I should not get short of breath anymore." "This drug will help my heart muscle pump less." "I may notice my heart rate decrease." "I may feel tired during early treatment."

"This drug will help my heart muscle pump less." Rationale: The ability to increase the strength of contractions is a characteristic of cardiac glycosides. It may result in a decrease in pulse. Initially the client may experience some fatigue. Symptoms of CHF, such as dyspnea, should improve.

At a clinic visit, the nurse provides dietary teaching for a 56-year-old woman who was recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement? A "I will limit the amount of milk and cheese in my diet." B "I can add salt when cooking foods but not at the table." C "I will take an extra diuretic pill when I eat a lot of salt." D "I can have unlimited amounts of foods labeled as reduced sodium ."

A "I will limit the amount of milk and cheese in my diet." Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt should not be added during food preparation or at the table. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake. Foods labeled as reduced sodium contain at least 25% less sodium than regular.

A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate? a. "Because you have diabetes, you would not be a candidate for a heart transplant." b. "The choice of a patient for a heart transplant depends on many different factors." c. "Your heart failure has not reached the stage in which heart transplants are needed." d. "People who have heart transplants are at risk for multiple complications after surgery."

ANS: B Indications for a heart transplant include end-stage heart failure (Stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patient's question

Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations. b. b-adrenergic blockers. c. calcium channel blockers. d. angiotensin-converting enzyme (ACE) inhibitors.

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 medications such as ACE-inhibitors, diuretics, and b-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The b-adrenergic blockers are not used as initial therapy for new onset heart failure

The nurse is caring for a patient who is receiving IV furosemide (Lasix) 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 pounds in 24 hours b. Hourly urine output greater than 60 mL c. Reduction in patient complaints of chest pain d. Reduced dyspnea with the head of bed at 30 degrees

ANS: D 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 also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patient's response

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

B Hypotension and tachycardia Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? A Fatigue, orthopnea, and dependent edema B Severe dyspnea and blood-streaked, frothy sputum C Temperature is 100.4o F and pulse is 102 beats/minute D Respirations 26 breaths/minute despite oxygen by nasal cannula

B Severe dyspnea and blood-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths per minute, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? A ADHF B Chronic HF C Left-sided HF D Right-sided HF

D Right-sided HF An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

The nurse developing a teaching plan for a client receiving thiazide diuretics should include the following. Teaching the client to take apical pulse. Decreasing potassium-rich foods in the diet. Including citrus fruits, melons, and vegetables in the diet. Teaching the client to check blood pressure t.i.d.

Including citrus fruits, melons, and vegetables in the diet. Rationale: Thiazide diuretics are potassium wasting, and levels should be closely monitored. Encouraging foods rich in potassium could help maintain potassium levels. Taking an apical pulse is indicated before administering cardiac glycosides and beta blockers. It would not be necessary to check blood pressure TID unless the client was experiencing hypotension.

The client is prescribed captopril (Capoten) for treatment of HF. The nurse teaches that the primary action of the drug is to Prevent influx of calcium. Lower peripheral resistance and reduce blood volume. Increase strength of ventricular contractions. Increase heart rate.

Lower peripheral resistance and reduce blood volume. Rationale: ACE inhibitors decrease peripheral resistance and reduce blood volume by enhancing the excretion of sodium and water. This results in decreased afterload and increased cardiac output.

7] The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive highest priority? a. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles b. Confusion, urine output 15mL over the last 2 hours, orthopnea. c. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities. d. Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise.

b. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are stable

24] A 58-year-old female with a family history of CAD is being seen for her annual physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse? a. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." b. "The triglycerides are elevated and will not return to normal without these medications." c. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." d. "The medications are not indicated since your lab values are all normal."

c. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, post-menopausal age, LDL above optimum levels and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke.

31] Crackles heard on lung auscultation indicate which of the following? a. Cyanosis b. Bronchospasm c. Airway narrowing d. Fluid-filled alveoli

d. Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

23] The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease? a. a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. b. a 43-year-old male with a family history of CAD and cholesterol level of 158 c. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor) d. A 65-year-old female who is obese with an LDL of 188

d. The woman who is 65-years-old, over weight and has an elevated LDL is at greatest risk. Total cholesterol >200, LDL >100, HDL <40 in men, HDL <50 in women, men 45-years and older, women 55-years and older, smoking and obesity increase the risk of CAD. Atorvastatin is a medication to reduce LDL and decrease risk of CAD. The combination of postmenopausal, obesity and high LDL cholesterol places this client at greatest risk.

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 ADHF? A Take medications as prescribed. B Use oxygen when feeling short of breath. C Only ask the physician's office questions. D Encourage most activity in the morning when rested.

A Take medications as prescribed. The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF.

25] If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: a. Explaining how the old behavior leads to poor health b. Withholding praise until the new behavior is well established c. Rewarding the client whenever the acceptable behavior is performed d. Instilling mild fear into the client to extinguish the behavior

c. A basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.

43] Sublingual nitroglycerine tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? a. Take one tablet every 2 to 5 minutes until the pains stops b. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes c. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets d. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician

c. The correct protocol for nitroglycerin use involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of three tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes.

A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as a. orthopnea. b. pulsus alternans. c. paroxysmal nocturnal dyspnea. d. acute bilateral pleural effusion.

ANS: C Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period

A patient with chronic HF and atrial fibrillation is treated with a digitalis glycoside and a loop diuretic. To prevent possible complications of this combination of drugs, what does the nurse need to do (select all that apply)? a. Monitor serum potassium levels b. teach the patient how to take a pulse rate.

Hypokalemia, which can be caused by the use of potassium-depleting diuretics (e.g., thiazides, loop diuretics), is one of the most common causes of digitalis toxicity. Low serum levels of potassium enhance the action of digitalis, causing a therapeutic dose to achieve toxic levels. Hypokalemia can also precipitate dysrhythmias. Monitoring the serum potassium levels of patients receiving digitalis preparations and potassium-depleting diuretics is essential. Patients taking digitalis preparations should be taught how to measure their pulse rate because bradycardia and atrioventricular blocks are late signs of digitalis toxicity. In addition, patients should know what pulse rate would necessitate a call to the health care provider.