Ch 34: Heart Failure

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

a, b. Diastolic failure is characterized by abnormal resistance to ventricular filling. Hypertension, coronary artery disease (CAD), advanced age, and diabetes are all risk factors for heart failure (HF). Ejection fraction (EF) is decreased in systolic HF. Decreased cardiac output (CO) and increased workload and oxygen requirements of the myocardium precipitate HF due to left ventricle dysfunction.

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

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

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

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

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

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

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

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

Priority Decision: The nurse reviews the following vital signs recorded by an unlicensed assistive personnel (UAP) on a patient with acute decompensated heart failure (ADHF): BP 98/60, HR 102 bpm, RR 24, temp 98.2° F (36.7° C), SpO2 84% on 2 L/min via nasal cannula. a. Which of these findings is of highest priority? b. What should the nurse do next?

a. SpO2 of 84% on 2 L/min via nasal cannula indicates impaired oxygen saturation. The patient is having trouble with gas exchange. Airway and breathing are the priority (follow ABCs). b. The nurse should place the patient in high Fowler's position, assess the patient immediately, recheck SpO2, auscultate breath sounds, assess level of consciousness (LOC), check the oxygen connection and rate setting (2 L/min), and talk with the patient about her or his breathing.

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

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

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

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

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

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

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

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

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

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

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

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

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

c. Not adding salt to foods will not eliminate enough sodium for the 2400-mg sodium diet. All foods that are high in sodium should be eliminated in a 2400-mg sodium diet, in addition to the elimination of salt during cooking. Examples include obviously salted foods as well as unexpected sodium sources that are identified by reading the label of prepared foods and medicines.

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

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

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

c. b-type natriuretic peptide (BNP) is released from the ventricles in response to increased blood volume in the heart and is a good marker for heart failure. If BNP is elevated, shortness of breath is due to heart failure; if BNP is normal, dyspnea is due to pulmonary disease. BNP opposes the actions of the RAAS, resulting in vasodilation and reduction in blood volume. Exercise stress testing and cardiac catheterization are more important tests to diagnose coronary artery disease, and although the blood urea nitrogen (BUN) may be elevated in heart failure, it is a reflection of decreased renal perfusion. (See Table 31-6.)

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

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

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

d. FACES is used to teach patients to identify early HF symptoms. F = Fatigue; A = Activity limitations; C =Chest congestion/cough; E = Edema; S = Shortness of breath. The other options are not correct.

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

d. Further teaching is needed if the patient believes a weight gain of 2 to 3 pounds in 2 days is an indication for dieting. In a patient with heart failure, this type of weight gain reflects fluid retention and is a sign of heart failure that should be reported to the HCP. The other options show patient understanding of the heart failure management teaching (see Table 34-10).

Which medication shows improvement in HF for African American patients for hypertension and angina? a. Captopril b. Nitroglycerin c. Spironolactone (Aldactone) d. Isosorbide dinitrate and hydralazine (BiDil)

d. Isosorbide dinitrate and hydralazine (BiDil) is recommended for use in African American patients with HF to treat hypertension and angina. Captopril is used for hypertension by all patients. Nitroglycerin is used with hydralazine for patients who cannot tolerate RAAS inhibitors (ACE inhibitors or ARBs) for heart failure management. Spironolactone (Aldactone) is used for hypertension.

The nurse assesses the patient with chronic biventricular heart failure for paroxysmal nocturnal dyspnea (PND) by questioning the patient regarding a. the presence of restlessness and confusion. b. frequent awakening to void during the night. c. the presence of swelling in dependent body areas. d. waking in a panic with a feeling of suffocation.

d. Paroxysmal nocturnal dyspnea (PND) is awakening from sleep with a feeling of suffocation and a need to sit up to be able to breathe. Patients learn that sleeping with the upper body elevated on several pillows helps to prevent PND. Behavior changes are seen in late stages of HF. Nocturia occurs with HF as fluid moves back into the vascular system during recumbency, increasing renal blood flow. Dependent edema does not indicate PND.

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

d. The 52-yr-old woman does not have any contraindications for cardiac transplantation, even though she lacks the indication of adequate financial resources. The 24-yr-old man does not have a current cardiac diagnosis. The postoperative transplant regimen is complex and rigorous, and patients who have not been compliant with other treatments or who may not have the means to understand the care would not be good candidates. A history of drug or alcohol abuse is usually a contraindication to heart transplant.