Chapter 35 Care of Patients with Cardiac Problems

The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching?

"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 providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching?

"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 pounds (1.4 kg) in a week or 1-2 pounds (0.45 to 0.9 kg) overnight. The client would begin by walking 200 to 400 feet (61 to 123 meters) per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure. The provider must be notified if this occurs.

The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best respone?

"This may be caused by a genetic trait." The nurse's best 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.

After receiving change-of-shift report about these four clients, which client would the nurse assess first?

A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions (PVCs) 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 manifestations 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 home health nurse visits a client with heart failure who has gained 5 pound (2.3kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take?

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.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)?

B-type natriuretic peptide (BNP) of 760 pg/mL (760 ng/dL) A BNP of 760 pg/ml (760 ng/dL) is consistent with a diagnosis of heart failure. BNP is produced and released by the ventricles when the client has fluid overload as a result of HF. A normal BNP value is less than 0-99 picograms per milliliter (pg/mL) or 0-99 nanograms per liter (ng/L).Hypokalemia (serum potassium level of 3.2 mEq/L [3.2 mmol/L]) may occur in response to diuretic therapy for HF, but may also occur with other conditions. It is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.

The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider?

Blurred Vision Fatigue Anorexia

Which medication, she given in heart failure, may improve morbidity and mortality?

Carvedilol (Coreg)

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess?

Chest discomfort or pain Tachycardia Fatigue

How does the nurse in the cardiac clinic recognizie that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen?

Client states that she is able to 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 workin on the telemetry unit?

Client with heart failure who is receiving dobutamine (Dobutrex) 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.

A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it to all end." What is the nurse's best response?

Considers further assessment for depression The nurse's best response to the client when he/she says it isn't worth it anymore and I want it all to end is to consider further assessment for depression. This client is at risk for depression because of the diagnosis of heart failure, and further assessment must be done.Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope, and ignores the client's feelings.

The nurse in the emergency department is caring for a client with acute HF who is experiencing sever dyspnea, with pink, frothy sputum, and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Physical Assessment Findings Diagnostic Findings Provider Prescriptions Crackles in all fieldsS3 presentOliguriaEjection fraction 30%BNP 560Sodium 130 mEq/L (130 mmol/L)Diagnosis: heart failureEnalapril 10 mg orally dailyHeparin 5000 units subcutaneously every 12 hoursFurosemide 40 mg IV dailyStrict I & O

Furosemide While caring for a client with acute heart failure, the ED nurse Administers Furosemide first. The client is displaying typical signs of acute pulmonary edema secondary to fluid-filled alveoli and pulmonary congestion. A diuretic will promote fluid loss.Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis secondary to immobility, but will not reduce fluid excess. Although all clients with congestive heart failure need to have daily weights and I & O monitored, this is not a priority. Removing fluid volume and treating dyspnea are matters of priority.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temp 99.8F, Pulse 48BPM, RR 20.min, Potassium 3.2. What action does the nurse take?

Hold the digoxin, and obtain a prescription for a potassium supplement. The nurse needs to hold the digoxin and get 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.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as the worsening of the client's HF?

Ibuprofen (Motrin) The nurse questions an 82-year-old client with exacerbation of heart failure if the client is taking ibuprofen. Long-term use of nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF.A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism. It does not cause HF.

Which nursing action may be delegated to an unlicensed assistive personnel (UAP) working on the medical unit?

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.

Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea?

Place the client in high-Fowler's 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's position with the legs down. High-Fowler's 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 now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client?

Positions the client to alleviate dyspnea The ICU 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.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this prescription?

Serum 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.

The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of ineffective endocarditis instead of pericarditis or rheumatic carditis?

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.

A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result 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 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 pounds (2.5 kg) in one day. The best indicator of fluid volume gain or loss is daily weight. Because each kilogram represents approximately 1 liter, 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 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 (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medicaiton?

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.

When following up in the clinic with a client with HF, how does the nurse recognize that the client has been compliant with fluid restrictions?

Weight loss of 6 pounds (2.7 kg) since the last visit The clinic nurse recognizes that the client has been compliant with fluid restrictions when the client has a weight loss of 6 pounds (2.7 kg) since the last visit. Weight loss in this client indicates effective fluid restriction and diuretic drug therapy.Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions. Alternative methods of treating dry mouth need to be explored.