Heart Failure

Which drug is an angiotensin-converting enzyme (ACE) inhibitor? a. Captopril (Capoten) b. Furosemide (Lasix) c. Spironolactone (Aldactone) d. Chlorothiazide (Diuril)

ANS: A Capoten is a drug in an ACE inhibitor. Lasix is a loop diuretic. Aldactone blocks the action of aldosterone. Diuril works on the distal tubules.

A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.

A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action? a. Administer the Vasotec. b. Recheck the blood pressure. c. Hold the Vasotec. d. Notify the health care provider.

ANS: A The nurse should administer the medication. Generally, the health care provider will maintain the client's blood pressure between 90 and 110 mm Hg.

The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's best intervention? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply.) a. Hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria

ANS: A, B, E, F The hematocrit is low (should be 42.6%), indicating a dilutional ratio of red blood cells (RBCs) to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart.

The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"

ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level.

The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."

ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

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 all to end." What is the nurse's best response? a. Calls the family to lift the client's spirits b. Considers further assessment for depression c. Sedates the client to decrease myocardial oxygen demand d. Tells the client that things will get better

ANS: B This client is at risk for depression because of the diagnosis of heart failure, and further assessment should 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.

A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply. a. Peripheral edema b. Crackles in both lungs c. Breathlessness d. Ascites e. Tachypnea

ANS: B, C, E Clients with left-sided heart failure will exhibit symptoms such as fatigue, dyspnea or breathlessness, and crackles on auscultation of breath sounds. Peripheral edema and ascites are associated with right-sided heart failure.

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? (Select all that apply.) a. Hypokalemia b. Sinus bradycardia c. Fatigue d. Serum digoxin level of 1.5 e. Anorexia

ANS: B, C, E Digoxin toxicity may cause bradycardia. Fatigue and anorexia are symptoms of digoxin toxicity. Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. A serum digoxin level between 0.8 and 2.0 is considered normal and is not a symptom.

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

ANS: C 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 to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.

A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A decrease in blood pressure and urine output b. An increase in creatinine and extremity edema c. An increase in heart rate and respiratory rate d. A decrease in respirations and oxygen saturation

ANS: C In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? a. Auscultation of crackles b. Pedal edema c. Weight loss of 6 pounds since the last visit d. Reports sucking on ice chips all day for dry mouth

ANS: C 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 should be explored.

Nursing care for the child in congestive heart failure includes a. Counting the number of saturated diapers b. Putting the infant in the Trendelenburg position c. Removing oxygen while the infant is crying d. Organizing care to provide rest periods

ANS: D Diapers must be weighed for an accurate record of output. The head of the bed should be raised to decrease the work of breathing. Oxygen should be administered during stressful periods such as when the child is crying. Nursing care should be planned to allow for periods of undisturbed rest.

For what reason might a newborn infant with a cardiac defect, such as coarctation of the aorta, that results in a right-to-left shunt receive prostaglandin E1? a. To decrease inflammation b. To control pain c. To decrease respirations d. To improve oxygenation

ANS: D Prostaglandin E1 is used to maintain a patent ductus arteriosus, thus increasing pulmonary blood flow.

A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention? a. Assess respiratory status. b. Monitor electrolyte levels. c. Administer intravenous fluids. d. Insert a Foley catheter.

ANS: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously.

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? a. "I will call the provider if I have a cough lasting 3 or more days." b. "I will report to the provider weight loss of 2 to 3 pounds in a day." c. "I will try walking for 1 hour each day." d. "I should expect occasional chest pain."

ANS: A Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified. The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.

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? a. "I should avoid eating hamburgers." b. "I must cut out bacon and canned foods." c. "I shouldn't put the salt shaker on the table anymore." d. "I should avoid lunchmeats but may cook my own turkey."

ANS: A Cutting out beef or hamburgers made at home is not necessary; however, 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; these are to be avoided. The client correctly understands that adding salt to food should be avoided.

An older adult client with heart failure states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response? a. "Would you like to talk about this more?" b. "You're lucky to have such a devoted daughter." c. "You must feel as though you are a burden." d. "Would you like an antidepressant medication?"

ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly.

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."

ANS: A Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority? a. Echocardiography b. Chest x-ray c. T4 and thyroid-stimulating hormone (TSH) d. Arterial blood gas

ANS: A Echocardiography is considered the best tool for the diagnosis of heart failure. A chest x-ray probably will be done, and if the client has dyspnea, an arterial blood gas will be drawn, but the echocardiogram is the priority. T4 and TSH might be ordered to assess for a contributing cause of heart failure.

What intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure? a. Weigh the infant every day on the same scale at the same time. b. Notify the physician when weight gain exceeds more than 20 g/day. c. Put the infant in a car seat to minimize movement. d. Administer digoxin (Lanoxin) as ordered by the physician.

ANS: A Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention. Weighing the infant on the same scale at the same time each day ensures consistency. An excessive weight gain for an infant is an increase of more than 50 g/day. With fluid volume excess, skin will be edematous. The infant's position should be changed frequently to prevent undesirable pooling of fluid in certain areas. Lanoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid.

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 to the worsening of the client's HF? a. Ibuprofen (Motrin) b. Hydrochlorothiazide (HydroDIURIL) c. NPH insulin d. Levothyroxine (Synthroid)

ANS: A Long-term use of nonsteroidal anti-inflammatory 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.

A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication? a. Insert a separate IV access. b. Prepare a test bolus dose. c. Prepare the piggyback line. d. Administer furosemide (Lasix) first.

ANS: A Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin. A test bolus is not needed, nor is Lasix. Because the medication should be given through a separate IV, it is not necessary to prepare a piggyback line.

A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? a. Place the client in a high Fowler's position. b. Perform nasotracheal suctioning of the client. c. Auscultate the client's heart and lung sounds. d. Place the client on a 1000 mL fluid restriction.

ANS: A Placing a client in a high Fowler's position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client's heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed.

The nurse is caring for a client with severe heart failure. What is the best position in which to place this client? a. High Fowler's, pillows under arms b. Semi-Fowler's, with legs elevated c. High Fowler's, with legs elevated d. Semi-Fowler's, on the left side

ANS: A Placing the client in high Fowler's position, with pillows under the arms, allows for maximum chest expansion.

A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child's laboratory values, the nurse is not surprised to notice which abnormality? a. Polycythemia b. Infection c. Dehydration d. Anemia

ANS: A Polycythemia is a compensatory response to chronic hypoxia. The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood. Infection is not a clinical consequence of cyanosis. Although dehydration can occur in cyanotic heart disease, it is not a compensatory mechanism for chronic hypoxia. It is not a clinical consequence of cyanosis. Anemia may develop as a result of increased blood viscosity. Anemia is not a clinical consequence of cyanosis.

A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client? a. "Please come into the clinic for an evaluation." b. "Increase your fluid intake during waking hours." c. "Use an over-the-counter cough suppressant." d. "Sleep on two pillows to facilitate postnasal drainage."

ANS: A The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible.

In which situation is there a risk that a newborn infant will have a congenital heart defect (CHD)? a. Trisomy 21 detected on amniocentesis b. Family history of myocardial infarction c. Father has type 1 diabetes mellitus d. Older sibling born with Turner syndrome

ANS: A The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin dependent have an increased risk of CHD. Infants identified as having certain genetic defects, such as Turner syndrome, have a higher incidence of CHD. A family history is not a risk factor.

Before giving a dose of digoxin (Lanoxin), the nurse checked an infant's apical heart rate and it was 114 bpm. What should the nurse do next? a. Administer the dose as ordered. b. Hold the medication until the next dose. c. Wait and recheck the apical heart rate in 30 minutes. d. Notify the physician about the infant's heart rate.

ANS: A The infant's heart rate is above the lower limit for which the medication is held. A dose of Lanoxin is withheld for a heart rate less than 100 bpm in an infant. The infant's heart rate is acceptable for administering Lanoxin. It is unnecessary to recheck the heart rate at a later time.

Which CHD results in increased pulmonary blood flow? a. Ventricular septal defect b. Coarctation of the aorta c. Tetralogy of Fallot d. Pulmonary stenosis

ANS: A Ventricular septal defect causes a left-to-right shunting of blood, thus increasing pulmonary blood flow. Coarctation of the aorta is a stenotic lesion that causes increased resistance to blood flow from the proximal to distal aorta. THe defects associated with tetralogy of Fallot result in a right-to-left shunting of blood, thus decreasing pulmonary blood flow. Pulmonary stenosis causes obstruction of blood flow from the right ventricle to the pulmonary artery. Pulmonary blood flow is decreased.

The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. S3/S4 summation gallop f. Cough worsens at night

ANS: A, B, E, F Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle.

Before preparing a teaching plan for the parents of an infant with ductus arteriosus, it is important that the nurse understands this condition. Which statement best describes patent ductus arteriosus? a. Patent ductus arteriosus involves a defect that results in a right-to-left shunting of blood in the heart. b. Patent ductus arteriosus involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. c. Patent ductus arteriosus is a stenotic lesion that must be surgically corrected at birth. d. Patent ductus arteriosus causes an abnormal opening between the four chambers of the heart.

ANS: B A patent ductus arteriosus allows blood to flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. Patent ductus arteriosus is failure of the fetal shunt between the aorta and the pulmonary artery to close. Patent ductus arteriosus is not a stenotic lesion. Patent ductus arteriosus can be closed both medically and surgically. Atrioventricular defect occurs when fetal development of the endocardial cushions is disturbed, resulting in abnormalities in the atrial and ventricular septa and the atrioventricular valves.

The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect? a. Pulmonary stenosis b. Patent ductus arteriosus c. Ventricular septal defect d. Coarctation of the aorta

ANS: B A systolic ejection murmur that may be accompanied by a palpable thrill is a manifestation of pulmonary stenosis. The classic murmur associated with patent ductus arteriosus is a machinery-like one that can be heard through both systole and diastole. The characteristic murmur associated with ventricular septal defect is a loud, harsh, holosystolic murmur. A systolic murmur that is accompanied by an ejection click may be heard on auscultation when coarctation of the aorta is present.

The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client? a. Administer this medication before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level and check for symptoms of hypokalemia.

ANS: B Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension.

What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well? a. Recheck the infant's blood pressure. b. Alert the physician. c. Withhold oral feeding. d. Increase the oxygen rate.

ANS: B Although this may be indicated, it is not the priority action. These are signs of early congestive heart failure, and the physician should be notified. Withholding the infant's feeding is an incomplete response to the problem. Increasing oxygen may alleviate symptoms, but medications such as digoxin and furosemide are necessary to improve heart function and fluid retention. Notifying the physician is the priority nursing action.

A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? a. The client's ability to understand medication teaching b. The risk for hypotension c. The potential for bradycardia d. Liver function tests

ANS: B Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, understanding of teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

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

ANS: B Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds. Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse should 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 medication, when given in heart failure, may improve morbidity and mortality? a. Dobutamine (Dobutrex) b. Carvedilol (Coreg) c. Digoxin (Lanoxin) d. Bumetanide (Bumex)

ANS: B Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; this category of pharmacologic agents improves morbidity, mortality, and quality of life. Dobutamine and digoxin are inotropic agents used to improve myocardial contractility but have not been directly associated with improving morbidity and mortality. Bumetanide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.

The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction? a. "Walk until you become short of breath and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."

ANS: B Gathering all supplies needed for a chore at one time decreases the amount of energy needed.

An older adult taking digoxin and hydrochlorothiazide (HCTZ) for chronic heart failure is admitted to the emergency department (ED) with an apical pulse of 48. A family member states that the client has reported blurred vision and loss of appetite for 2 weeks. What is the nurse's first action? a. Call the ED physician immediately b. Draw a serum digoxin level c. Assess for signs of hypokalemia d. Establish the client's airway

ANS: B The clinical manifestations of digoxin toxicity are often vague and nonspecific and include anorexia, fatigue, blurred vision, and changes in mental status, especially in older adults. Older adults are more likely than other patients to become toxic because of decreased renal excretion.

Which strategy is appropriate when feeding the infant with congestive heart failure? a. Continue the feeding until a sufficient amount of formula is taken. b. Limit feeding time to no more than 30 minutes. c. Always bottle feed every 4 hours. d. Feed larger volumes of concentrated formula less frequently.

ANS: B The infant with congestive heart failure may tire easily. If the infant does not consume an adequate amount of formula in 30 minutes, gavage feedings should be considered. The infant with congestive heart failure may tire easily, so the feeding should not continue beyond 30 minutes. Infants with congestive heart failure may be breastfed. Feedings every 3 hours is a frequently used interval. If the infant were fed less frequently than every 3 hours, more formula would need to be consumed and would tire the infant. The infant is fed smaller amounts of concentrated formula every 3 hours.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day." c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."

ANS: B Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

The nurse discovers a heart murmur in an infant 1 hour after birth. She is aware that fetal shunts are closed in the neonate at what point? a. When the umbilical cord is cut b. Within several days of birth c. Within a month after birth d. By the end of the first year of life

ANS: B With the neonate's first breath, gas exchange is transferred from the placenta to the lungs. The separation of the fetus from the umbilical cord does not contribute to the establishment of neonatal circulation. In the normal neonate, fetal shunts functionally close in response to pressure changes in the systemic and pulmonary circulations and to increased oxygen content. This process may take several days to complete. The fetal shunts normally close within several days of birth, but may take several days.

The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? a. "I have been drinking more water than usual." b. "I have been awakened by the need to urinate at night." c. "I have to stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea; pink, frothy sputum; and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Crackles in all fields S3 present Oliguria Ejection fraction 30% BNP 560 Sodium 130 mEq/L Diagnosis: heart failure Enalapril 10 mg orally daily Heparin 5000 units subcutaneously every 12 hours Furosemide 40 mg IV daily Strict I & O Which prescription does the nurse implement first? a. Enalapril b. Heparin c. Furosemide d. Intake and output (I&O)

ANS: C 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 should have daily weights and I & O monitored, this is not a priority; removing fluid volume and treating dyspnea are matters of priority.

A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if what condition occurs? Select all that apply. a. Respiratory rate of 36 at rest b. Appetite slowly increasing c. Temperature above 37.7° C (100° F) d. New, frequent coughing e. Turning blue or bluer than normal

ANS: C, D, E The parents should be instructed to notify the physician after their infant's cardiac surgery fora temperature above 37.7o C; new, frequent coughing; and any episodes of the infant turning blue or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations, and it is expected that the appetite will increase slowly.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? a. Give the digoxin; reassess the heart rate in 30 minutes. b. Give the digoxin; document assessment findings in the medical record. c. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. d. Hold the digoxin, and obtain a prescription for a potassium supplement.

ANS: D Digoxin causes bradycardia; hypokalemia potentiates digoxin. Because digoxin causes bradycardia, the medication should be held. Furosemide decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid volume excess at this time.

A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? a. Cough b. Headache c. Pulse of 62 beats/min d. Potassium of 2.9 mEq/L

ANS: D Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headache may occur with any medication and is not a serious side effect. Bradycardia is not likely to occur with this medication.

What is an expected assessment finding in a child with coarctation of the aorta? a. Orthostatic hypotension b. Systolic hypertension in the lower extremities c. Blood pressure higher on the left side of the body d. Disparity in blood pressure between the upper and lower extremities

ANS: D Orthostatic hypotension is not present with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities. The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation. The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities.

A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should the nurse do first when the baby is crying and becomes severely cyanotic? a. Place the infant in a knee-chest position. b. Administer oxygen. c. Administer morphine sulfate. d. Calm the infant.

ANS: D Placing the infant in a knee-chest position will decrease venous return so that smaller amounts of highly saturated blood reach the heart. This should be done after calming the infant. Administering oxygen is indicated after placing the infant in a knee-chest position. Administering morphine sulfate calms the infant. It may be indicated some time after the infant has been calmed. Calming the crying infant is the first response. An infant with unrepaired tetralogy of Fallot who is crying and agitated may eventually lose consciousness.

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? a. Determines the client's physical limitations b. Encourages alternate rest and activity periods c. Monitors and documents heart rate, rhythm, and pulses d. Positions the client to alleviate dyspnea

ANS: D Positioning the client to alleviate dyspnea 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 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? a. The client has diuresis of 400 mL in 24 hours b. The client's blood pressure is 122/84 mm Hg c. The client has an aplical pulse of 82 beats/min d. The client's weight decreases by 2.5 kg

ANS: D 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.

A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? a. Place the client in a high Fowler's position. b. Begin cardiopulmonary resuscitation (CPR). c. Promote rest and minimize activities. d. Administer loop diuretics as prescribed.

ANS: D The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler's position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.

The client who just started taking isosorbide dinitrate (Imdur) reports a headache. What is the nurse's best action? a. Titrate oxygen to relieve headache. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

ANS: D The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen.

A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."

ANS: A Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.

Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries

ANS: C Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. The atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Transposition of the great arteries results in mixed blood flow.

The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity? a. Decrease in oxygen saturation from 98% to 95% b. Respiratory rate change from 22 to 28 breaths/min c. Systolic blood pressure change from 136 to 96 mm Hg d. Increase in heart rate from 86 to 100 beats/min

NS: C A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.

The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes cigarettes daily d. Older man who has had a myocardial infarction

ANS: A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.

What is the nurse's first action when planning to teach the parents of an infant with a CHD? a. Assess the parents' anxiety level and readiness to learn. b. Gather literature for the parents. c. Secure a quiet place for teaching. d. Discuss the plan with the nursing team.

ANS: A Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn or have high anxiety. Decreasing level of anxiety is often needed before new information can be processed. A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents' knowledge and readiness.

A beneficial effect of administering digoxin (Lanoxin) is that it a. Decreases edema b. Decreases cardiac output c. Increases heart size d. Increases venous pressure

ANS: A Digoxin has a rapid onset and is useful increasing cardiac output, decreasing venous pressure, and as a result, decreasing edema. Cardiac output is increased by digoxin. Heart size is decreased by digoxin. Digoxin decreases venous pressure.

The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate

ANS: A Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. Dysphagia, sacral edema, and an irregular heart rate are not related to pulmonary edema.

The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? (Select all that apply.) a. Chest discomfort or pain b. Tachycardia c. Expectorating thick, yellow sputum d. Sleeping on back without a pillow e. Fatigue

ANS: A, B, E 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.

A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? a. Serum sodium level of 135 mEq/L b. Serum potassium level of 2.8 mEq/L c. Serum creatinine of 1.0 mg/dL d. Serum magnesium level of 1.9 mEq/L

ANS: B Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy. A serum sodium level of 135 mEq/L is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L represents a normal value.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? a. Ejection fraction is 25% b. Client states that she is able to sleep on one pillow c. Client was hospitalized five times last year with pulmonary edema d. Client reports that she experiences palpitations

ANS: B Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. 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.

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? a. Lowered heart rate b. Increased myocardial contractility c. Decreased conduction through the AV node d. Vasoconstriction of the renal blood vessels

ANS: B Increased myocardial contractility -- thus increasing CO

The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention? a. Insert an indwelling urinary catheter. b. Monitor the client's blood pressure. c. Place the nitroglycerin under the client's tongue. d. Monitor the client's serum glucose level.

ANS: B Intravenous nitroglycerin and furosemide will decrease the client's blood pressure, so it is important to monitor closely for hypotension. Intravenous medications are not administered under the tongue. Although the client may need an indwelling urinary catheter to monitor output, it is not the priority. The client's glucose levels should not be affected by these medications.

The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans.

ANS: B The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left.

As a nurse working in the newborn nursery, you notice an infant who is having circumoral cyanosis. Which CHD do you suspect the child may have? Select all that apply. a. Patent ductus arteriosus (PDA) b. Tetralogy of Fallot c. Pulmonary atresia d. Transposition of the great arteries e. Ventricular septal defect

ANS: B, C, D Tetralogy of Fallot is a cyanotic lesion with decreased pulmonary blood flow. The hypoxia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach normal range. Pulmonary atresia is a cyanotic lesion with decreased pulmonary blood flow. The hypxoia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach the normal range. Transposition of the great arteries is a cyanotic lesion with increased pulmonary blood flow. PDA is a failure of the fetal shunt between the aorta and the pulmonary artery to close. PDA is not classified as a cyanotic heart disease. Prostaglandin E1 is often given to maintain dudctal patency in children with cyanotic heart diseases. VSD is the most common type of cardiac defect. The VSD is a left-to-right shunting defect; however, it may be accompanied by other defects.

Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? a. Serum potassium level of 3.2 mEq/L b. Ejection fraction of 60% c. B-type natriuretic peptide (BNP) of 760 ng/dL d. Chest x-ray report showing right middle lobe consolidation

ANS: C BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia 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.

When assessing a child for possible congenital heart defects (CHDs), where should the nurse measure blood pressure? a. The right arm b. The left arm c. All four extremities d. Both arms while the child is crying

ANS: C Blood pressure measurements for upper and lower extremities are compared during an assessment for CHDs. Discrepancies in blood pressure between the upper and lower extremities cannot be determined if blood pressure is not measured in all four extremities. When a CHD is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease. Blood pressure measurements when the child are crying are likely to be elevated; thus the readings will be inaccurate. Also, all four extremities need to be measured.

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

ANS: C 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 should not be delegated.

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

ANS: C 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 should prevent this situation.

A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2 mEq/L. What is the nurse's best action at this time? a. Assess the client's oxygen saturation level b. Ask the laboratory to retest the potassium level c. Give potassium as an IV infusion d. Check the client's serum creatinine

ANS: D Clients who are hyperkalemic (those with an elevated serum potassium level) may also be in renal failure. The client's serum creatinine should be reviewed to determine if it is greater than 1.8 mg/dL, at which time the health care provider should be notified before administering any supplemental potassium.

A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.

The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.

Which statement suggests that a parent understands how to correctly administer digoxin? a. "I measure the amount I am supposed to give with a teaspoon." b. "I put the medicine in the baby's bottle." c. "When she spits up right after I give the medicine, I give her another dose." d. "I give the medicine at 8 in the morning and evening every day."

ANS: D To ensure the correct dosage, the medication should be measured with a syringe. The medication should not be mixed with formula or food. It is difficult to judge whether the child received the proper dose if the medication is placed in food or formula. To prevent toxicity, the parent should not repeat the dose without contacting the child's physician. For maximum effectiveness, the medication should be given at the same time everyday.

While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next? a. Document this finding in the patient's record. b. Obtain vital signs, including oxygen saturation. c. Have the patient perform the Valsalva maneuver. d. Observe for JVD with the patient upright at 45 degrees.

ANS: D When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the JVD in the medical record if it persists when the head is elevated.