Chapter 32

The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which client statement indicates understanding of the teaching? "I should expect occasional chest pain." "I will try walking for 1 hour each day." "I will report to the provider weight loss of 2 to 3 lb (0.9 to 1.4 kg) in a day." "I will call the provider if I have a cough lasting 3 or more days."

"I will call the provider if I have a cough lasting 3 or more days." The client understands the discharge teaching about when to seek medical attention when the client says: "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; it is important to notify the provider if this occurs.The client would call the provider for weight gain of 3 lb (1.4 kg) in a week or 1-2 lb (0.45 to 0.9 kg) overnight. The client would begin by walking 200 to 400 feet (61 to 123 m) per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure. The provider must be notified if this occurs.

After receiving change-of-shift report about these four clients, which client would the nurse assess first? A 79 year old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min. A 55 year old admitted with pulmonary edema who received furosemideand whose current O2 saturation is 94%. A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. A 68 year old with pericarditis who is reporting sharp chest pain with inspiration.

A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions. The nurse would first assess the 46 year old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical signs and symptoms of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia.The 55 year old is stable and can be assessed after the client with aortic stenosis. The 68 year old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79 year old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.

The nurse caring for a client with heart failure who is taking digoxin. What assessment data requires that nurse notify the health care provider? (Select all that apply.) Select all that apply. Anorexia Blurred vision Fatigue Heart rate 110/beats/min Serum digoxin level of 1.5 ng/mL (1.92 nmol/L)

Anorexia Blurred vision Fatigue The signs and symptoms of digoxin toxicity that the nurse notifies the provider include: blurred vision, fatigue, and anorexia. Changes in mental status, especially in older adults, may also occur. Sinus bradycardia and not tachycardia is a sign of digoxin toxicity. A serum digoxin level between 0.8 and 2.0 (1.02 and 2.56 nmol/L) is considered normal and is not a symptom.

The nurse is assessing a client with right-sided heart failure. What assessment findings will the nurse anticipate? (Select all that apply.) Select all that apply. Oliguria Ascites Pulmonary congestion Peripheral edema Shortness of breath Third heart sound

Ascites Peripheral edema Right-sided heart failure is associated with increased systemic venous pressure and congestion; producing signs such as peripheral edema, ascites, liver enlargement, and neck vein distension. Left-sided heart failure is associated with pulmonary congestion and can produce shortness of breath, weakness, fatigue, oliguria, and a third heart sound (S3 gallop).

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? Place the client in high-Fowler position with the legs down. Reassure the client that distress can be relieved with proper intervention. Ask a family member to remain with the client. Monitor pulse oximetry and cardiac rate and rhythm.

Place the client in high-Fowler position with the legs down. The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler position with the legs down. High-Fowler position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.

The nurse is caring for a client with heart failure in the coronary care unit. The client is exhibiting signs of air hunger and anxiety. Which nursing intervention will the nurse perform first for this client? Monitor and document heart rate, rhythm, and pulses. Encourage alternate rest and activity periods. Position the client to alleviate dyspnea. Determine the client's physical limitations.

Position the client to alleviate dyspnea. The nurse's first action is to position the client to alleviate dyspnea. This action will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action.Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.

The nurse is assessing a client with a cardiac infection. Which nursing assessment data causes the nurse to suspect infective endocarditis instead of pericarditis or rheumatic carditis? Thickening of the endocardium Pain aggravated by breathing, coughing, and swallowing Splinter hemorrhages Friction rub auscultated at the left lower sternal border

Splinter hemorrhages Splinter hemorrhages are indicative of infective endocarditis. Petechiae (pinpoint red spots) occur in many clients with endocarditis. Splinter hemorrhages appear as black longitudinal lines or small red streaks along the distal third of the nail bed.Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which client statement indicates the need for further teaching? "I won't put the salt shaker on the table anymore." "I need to avoid eating hamburgers." "I need to avoid lunchmeats but may cook my own turkey." "I must cut out bacon and canned foods."

"I need to avoid eating hamburgers." Further teaching about restricting sodium in the diet for a client with heart failure is needed when the client says, "I need to avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary, but fast-food hamburgers are to be avoided owing to higher sodium content.Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention, and must be avoided. The client correctly understands that adding salt to food must be avoided.

The nurse is caring a college athlete who collapsed during soccer practice. The client has been diagnosed with hypertrophic cardiomyopathy and states, "This can't be. I am in great shape. I eat right and exercise." Which nursing response is appropriate? "How does this make you feel?" "This can be caused by taking performance-enhancing drugs." "It could be worse if you weren't in good shape." "This may be caused by a genetic trait."

"This may be caused by a genetic trait." The appropriate nursing response is that this may be caused by a genetic trait. Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait.Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.

The home health nurse visits a client with heart failure who has gained 5 lb (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? Auscultate the client's posterior breath sounds. Notify the health care provider about the client's weight gain. Remind the client about dietary sodium restrictions. Assess the client for peripheral edema.

Auscultate the client's posterior breath sounds. The action the home care nurse takes first is to auscultate the heart failure client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the breath sounds must be assessed.Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse must notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

The nurse is caring for a client with heart failure in a cardiac clinic. What assessment data indicates that the client has demonstrated a positive outcome related to the addition of metoprolol to the medication regimen? Client states, "I can sleep on one pillow." Current ejection fraction is 25%. Client reports feeling like her heart beats very fast at times. Records indicate five episodes of pulmonary edema last year.

Client states, "I can sleep on one pillow." A client with heart failure has had a positive outcome to metoprolol when she states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represents a positive response to beta blockers such as metoprolol.An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest. This is not a positive outcome.

Which client is best to assign to an LPN/LVN working on the telemetry unit? Client with pericarditis who has a paradoxical pulse and distended jugular veins. Client with heart failure who is receiving dobutamine. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. Client with rheumatic fever who has a new systolic murmur.

Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. The best client to assign to the LPN/LVN working on the telemetry unit is the client with dilated cardiomyopathy who uses oxygen for exertional dyspnea. This client is the most stable. Administration of oxygen to a stable client is within the scope of LPN/LVN practice.The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the primary health care provider, which is within the scope of practice of the RN.

The nurse is caring for a client with heart failure. What assessment data will the nurse anticipate? (Select all that apply.) Select all that apply. Fatigue Sleeping on back without a pillow Chest discomfort or pain Tachycardia Expectorating thick, yellow sputum

Fatigue Chest discomfort or pain Tachycardia When caring for a client with heart failure, the nurse needs to assess for chest discomfort or pain, tachycardia, and fatigue. Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure.Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom. Clients usually find it difficult to lie flat because of dyspnea symptoms.

The nurse is preparing to administer digoxin as prescribed to a client with heart failure and notes: Temperature: 99.8° F (37.7° C), Pulse: 48 beats/min and irregular, Respirations: 20 breaths/min, Potassium level: 3.2 mEq/L (3.2 mmol/L). What action will the nurse take? Hold the digoxin, and obtain a prescription for an additional dose of furosemide. Hold the digoxin, and obtain a prescription for a potassium supplement. Give the digoxin; document assessment findings in the medical record. Give the digoxin; reassess the heart rate in 30 minutes.

Hold the digoxin, and obtain a prescription for a potassium supplement. The nurse needs to hold the digoxin and gets a prescription for a potassium supplement. Digoxin causes bradycardia and hypokalemia potentiates digoxin toxicity.Furosemide decreases circulating blood volume and depletes potassium. There is no indication suggesting that the client has fluid volume excess at this time.

Which nursing action may be delegated to assistive personnel (AP) working on the medical unit? Obtain daily weights for several clients with class IV heart failure. Check for peripheral edema in a client with endocarditis. Monitor the pain level for a client with acute pericarditis. Determine the usual alcohol intake for a client with cardiomyopathy.

Obtain daily weights for several clients with class IV heart failure. The nursing action that can be delegated to a UAP on the medical unit is to obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN.The role of the professional nurse is to perform assessments. Determining alcohol intake, monitoring pain level, and assessing for peripheral edema would not be delegated.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which nursing assessment data, obtained the day after admission, is the best indicator that the treatment has been effective? The client's weight decreases by 2.5 kg. The client has diuresis of 400 mL in 24 hours. The client's blood pressure is 122/84 mm Hg. The client has an apical pulse of 82 beats/min.

The client's weight decreases by 2.5 kg. The best indicator that treatment is effective on a client with heart failure and problems of hypervolemia is the client's weight decreased by 5.5 lb (2.5 kg) in 1 day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid.Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding alone, it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding alone, it is not significant to determine whether hypervolemia is relieved.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? The nurse monitors the client's pulse and blood pressure frequently. The client ambulates around the nursing unit with a walker. The nurse obtains a bedside commode before administering furosemide. The nurse returns the client to bed when the client becomes tachycardia.

The nurse obtains a bedside commode before administering furosemide. The nursing intervention that can help the client admitted today with heart failure is to have a bedside commode available to the client before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand. The nurse must prevent this situation.

A client begins therapy with lisinopril. What does the nurse consider at the start of therapy with this medication? The client's ability to understand medication teaching The potential for bradycardia Liver function tests The risk for hypotension

The risk for hypotension At the start of therapy with lisinopril, the nurse needs to consider the risk for hypotension. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.Although desirable, ability to understand teaching is not essential. ACE inhibitors are vasodilators and do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

A client with heart failure is prescribed furosemide. Which assessment data concerns the nurse with this new prescription? Serum sodium level of 135 mEq/L (135 mmol/L) Serum magnesium level of 1.9 mEq/L (0.95 mmol/L) Serum creatinine of 1.0 mg/dL (88.4 mcmol/L) Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

erum potassium level of 2.8 mEq/L (2.8 mmol/L) The nurse is concerned with the serum potassium level of 2.8 mEq/L (2.8 mmol/L) in a heart failure client taking furosemide. Furosemide is a loop diuretic and clients taking this drug must be monitored for potassium deficiency from diuretic therapy.A serum sodium level of 135 mEq/L (135 mmol/L) is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL (88.4 mcmol/L) represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L (0.95 mmol/L) represents a normal value.