Med Surge Prup U Chapter 28: Caring for Clients with Heart Failure - ML5

The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should monitor what assessment information? Skin turgor White blood cell count Peripheral pulses Potassium level

Potassium level Explanation: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole? Preload Stroke volume Afterload Ejection fraction

Preload Explanation: Preload is the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from a ventricle. The ejection fraction is the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole. Stroke volume is the amount of blood pumped out of the ventricle with each contraction.

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client? Pulmonary congestion Nausea Jugular venous distention Pedal edema

Pulmonary congestion Explanation: When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) Cough Dyspnea Pulmonary crackles Jugular vein distention Ascites

Pulmonary crackles Dyspnea Cough Explanation: The clinical manifestations of pulmonary congestion associated with left-sided heart failure include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels, but not ascites or jugular vein distention.

The nurse notes that a client has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem? Pericarditis Pulmonary edema Cardiomyopathy Right ventricular hypertrophy

Pulmonary edema Explanation: As a result of decreased cerebral oxygenation, the client with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the client's hands become cold and moist, the nail beds become cyanotic, and the skin turns ashen. The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.

The nurse notes that a client has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem? Pericarditis Pulmonary edema Cardiomyopathy Right ventricular hypertrophy

Pulmonary edema Explanation: As a result of decreased cerebral oxygenation, the client with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the client's hands become cold and moist, the nail beds become cyanotic, and the skin turns ashen. The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.

The nurse is caring for a client who developed a ventricular aneurysm as a complication of a myocardial infarction. The nurse will monitor this client closely for what problem associated with this issue? Signs of kidney damage Signs of a stroke Signs of infection Signs of another myocardial infarction

Signs of a stroke Explanation: A client who has a ventricular aneurysm will have thrombi that form in the crater of the bulging tissue. These thrombi could be propelled at any time from the heart into the brain which would cause a stroke. A ventricular aneurysm does not put the client at any additional risk for another MI, or infection or kidney damage.

A client is awaiting peripheral vascular surgery, specifically, a vascular graft. The nurse reviews the different options for grafting material the surgeon might use. What will be included in this discussion? Select all that apply. Teflon human tissue cotton Dacron silk

Teflon human tissue Dacron Explanation: Synthetic fibers such as Teflon and Dacron are usually used to make synthetic vascular grafts, but sometimes human tissue that has been harvested from cadavers is used. Cotton thread and silk are not synthetic fibers or human tissue and would therefore not be included in the discussion of grafting materials.

The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home? "My best time of the day is the morning." "I cut back on going up the steps during the day." "I eat six small meals a day when I am hungry." "My food tastes bland without salt."

"I cut back on going up the steps during the day." Explanation: Cutting back on activity like climbing stairs is an indication of a lessened ability to exercise. Eating small meals and not using salt are usually indicated for clients with heart failure. The client's assertion about morning being the best time of day is a vague statement.

The night before heart surgery involving a quadruple bypass, a client has been admitted and preoperatively prepared. The client has signed the consent for surgery. Which of the following statements indicates a greater need for teaching? "I know that I will have to perform deep breathing and coughing and will be ambulating early." "I know that I will be monitored closely in CCU after the surgery and I will be expected to participate in my care." "I will be relieved to have this su

"I will be relieved to have this surgery over with; I have a busy schedule at work right now and can`t afford downtime." Explanation: This statement indicates that the client thinks the surgery will solve the problem. The client doesn't appear to understand that other lifestyle changes need to be made. Distractors A, B, and D outline statements that indicate the person is an active participant and is following guidelines to help in recovery after the surgery or to promote heart health.

The nurse is caring for a client who is recovering from coronary artery bypass surgery. The client is concerned that the surgeon removed enough vein from the leg because there are only a few small wounds along the leg. The client says, "I have a friend who had this same surgery, and he has a big long incision on his leg. Why does mine look different?" What is the BEST response by the nurse to this client? "In your case, your surgeon used a scope to harvest the vein because there are fewe

"In your case, your surgeon used a scope to harvest the vein because there are fewer complications with this method." Explanation: The saphenous vein is now often harvested using an endoscope. It has many advantages over the long incision. It is a better cosmetic appearance, less muscle or wound damage, less pain, fewer wound infections, decrease in hospital stay, and fewer readmissions to the hospital.

A patient has been newly diagnosed with heart failure (HF) and has come to the meet with the nurse at the clinic for health education. What lifestyle recommendation should the nurse provide to this patient when discussing dietary modifications?

"It's in your best interests to avoid excessive fluids and sodium in your diet." Explanation: Lifestyle recommendations for the management of HF include restriction of dietary sodium; avoidance of excessive fluid intake, alcohol, and smoking; weight reduction when indicated; and regular exercise. It is unnecessary to increase potassium intake, replace complex carbohydrates, or eat frequent, smaller meals.

The nurse instructs a client with heart failure on restricting sodium in the diet. Which client statement indicates that teaching was effective? "Canned vegetables have low sodium content." "Food prepared at home is saltless unless I add it while cooking." "I will add a water softener to my water at home." "Lemon juice and herbs can be used to replace salt when cooking."

"Lemon juice and herbs can be used to replace salt when cooking." Explanation: For the client on a low-sodium or sodium-restricted diet, a variety of flavorings, such as lemon juice, vinegar, and herbs, may be used to improve the taste of the food and facilitate acceptance of the diet. Sodium is contained in municipal water. Water softeners also increase the sodium content of drinking water. Although the major source of sodium in the average American diet is salt, many types of natural foods contain varying amounts of sodium. Even if no salt is added in cooking and if salty foods are avoided, the daily diet will still contain about 2000 mg of sodium. Fresh fruits and vegetables are low in sodium and should be encouraged.

The nurse is reviewing the medication administration record of a client diagnosed with systolic heart failure. Which medication would the nurse anticipate administering to this client? A nonsteroidal anti-inflammatory drug (NSAID) An antiplatelet aggregator A beta-adrenergic blocker A calcium channel blocker

A beta-adrenergic blocker Explanation: Several medications are routinely prescribed for systolic heart failure, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.

The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg? Notify the health care provider of the chest pain. Hold any further treatment until the client's blood pressure increases. Administer the third sublingual nitroglycerin tablet. Wait ten minutes after the second tablet to assess pain.

Administer the third sublingual nitroglycerin tablet. Explanation: The nurse will need to administer the third sublingual nitroglycerin tablet. Nitroglycerin is given as three doses for chest pain as the client's blood pressure can tolerate it. The health care provider will be notified after three tablets. The nurse should not hold any further treatment if the client has chest pain. The dosing of nitroglycerin is a five-minute wait.

The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg? Notify the health care provider of the chest pain. Wait ten minutes after the second tablet to assess pain. Hold any further treatment until the client's blood pressure increases. Administer the third sublingual nitroglycerin tablet.

Administer the third sublingual nitroglycerin tablet. Explanation: The nurse will need to administer the third sublingual nitroglycerin tablet. Nitroglycerin is given as three doses for chest pain as the client's blood pressure can tolerate it. The health care provider will be notified after three tablets. The nurse should not hold any further treatment if the client has chest pain. The dosing of nitroglycerin is a five-minute wait.

The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg? Wait ten minutes after the second tablet to assess pain. Administer the third sublingual nitroglycerin tablet. Notify the health care provider of the chest pain. Hold any further treatment until the client's blood pressure increases.

Administer the third sublingual nitroglycerin tablet. Explanation: The nurse will need to administer the third sublingual nitroglycerin tablet. Nitroglycerin is given as three doses for chest pain as the client's blood pressure can tolerate it. The health care provider will be notified after three tablets. The nurse should not hold any further treatment if the client has chest pain. The dosing of nitroglycerin is a five-minute wait.

A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD? It is designed for extremely active patients. It never needs batteries. An LVAD only supports a failing left ventricle. It is specifically designed for long-term use.

An LVAD only supports a failing left ventricle. Explanation: A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.

A client will be placed on cardiopulmonary bypass for a mitral valve replacement. What type of medication will be required for this client? A calcium channel blocker A beta-adrenergic blocker An anticoagulant An antipyretic

An anticoagulant Explanation: One of the disadvantages of cardiopulmonary bypass is the need for anticoagulation. A calcium channel blocker, antipyretic, and beta-adrenergic blocker are not required for a client on cardiopulmonary bypass.

A 70-year-old man has been living with a diagnosis of heart failure (HF) for several years and has been vigilant about monitoring the trajectory of disease and adhering to his prescribed treatment regimen. The man has scheduled an appointment with his primary care provider because he has noted a weight gain of 6 pounds over the past week. The nurse should anticipate that this patient may benefit from which of the following treatment measures? An increase in the dose of his prescribed diuretic

An increase in the dose of his prescribed diuretic Explanation: If a patient with HF experiences a significant change in weight (i.e., 2- to 3-lb increase in a day or 5-lb increase in a week), the patient is instructed to notify his or her provider or to adjust the medications (e.g., increase the diuretic dose) per provider's directions. Thoracentesis is not relevant, and decreased activity may exacerbate the patient's condition. Decreased sodium intake may be of some benefit, but diuretics will have a greater effect.

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status? End-tidal CO2 Listening to breath sounds Pulse oximetry Arterial blood gases

Arterial blood gases Explanation: In left-sided heart failure, arterial blood gases may be obtained to assess ventilation and oxygenation.

The cardiac monitor alarm alerts the critical care nurse that the client is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how should the nurse describe this initial absence of cardiac rhythm?

Asystole Explanation: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.

The cardiac monitor alarm alerts the critical care nurse that the client is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how should the nurse describe this initial absence of cardiac rhythm? Asystole Pulseless electrical activity (PEA) Ventricular tachycardia Ventricular fibrillation

Asystole Explanation: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.

A client who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. Which aspect of the client's health history creates a heightened risk of intracardiac thrombi? Infective endocarditis Recurrent pneumonia Atrial fibrillation Recent surgery

Atrial fibrillation Explanation: Intracardiac thrombi are especially common in clients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.

A client who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. Which aspect of the client's health history creates a heightened risk of intracardiac thrombi? Recurrent pneumonia Atrial fibrillation Recent surgery Infective endocarditis

Atrial fibrillation Explanation: Intracardiac thrombi are especially common in clients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? Brain natriuretic peptide (BNP) Blood urea nitrogen (BUN) Creatinine Complete blood count (CBC)

Brain natriuretic peptide (BNP) Explanation: BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? Complete blood count (CBC) Brain natriuretic peptide (BNP) Blood urea nitrogen (BUN) Creatinine

Brain natriuretic peptide (BNP) Explanation: BNP is the key diagnostic indicator of heart failure. High levels of BNP are a sign of high cardiac filling pressure and can aid in the diagnosis of heart failure. A BUN, creatinine, and CBC are included in the initial workup.

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea? Observe for mist in the endotracheal tube. Attach a pulse oximeter probe and obtain values. Call for a chest x-ray. Listen for breath sounds over the epigastrium.

Call for a chest x-ray. Explanation: A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.

A nurse has performed an assessment of a patient and subsequently administered the patient's scheduled dose of ramipril, an angiotensin-converting enzyme (ACE) inhibitor prescribed for the treatment of the patient's longstanding heart failure (HF). The nurse understands that this drug will aid in the treatment of the patient's disease by: Reducing the patient's overall oxygen demand Reducing preload through the excretion of fluid and sodium Causing vasodilation and decreasing the heart's w

Causing vasodilation and decreasing the heart's workload Explanation: ACE inhibitors alleviate heart failure symptoms by causing vasodilation and decreasing myocardial workload. They do not have a positive inotropic effect and do not reduce oxygen demand. As well, ACE inhibitors do not promote the excretion of fluids and sodium like diuretics do.

A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next? Notify the health care provider. Administer potassium. Check the client's potassium level. Calculate the client's intake and output.

Check the client's potassium level. Explanation: The client is asymptomatic but has had a change in heart rhythm. More information is needed before calling the health care provider. Because the client is taking furosemide, a potassium-wasting diuretic, the next action would be to check the client's potassium level. The nurse would then call the health care provider with a more complete database. The health care provider will need to be notified after the nurse checks the latest potassium level. The intake and output will not change the heart rhythm. Administering potassium requires a health care provider's order.

The nurse is caring for a client with systolic heart failure whose previous adverse reactions rule out the safe use of angiotensin-converting enzyme (ACE) inhibitors. The nurse should anticipate that the prescriber may choose which combination of drugs? Combination of digoxin and normal saline Loop diuretic and antiplatelet aggregator Loop diuretic and calcium channel blocker Combination of hydralazine and isosorbide dinitrate

Combination of hydralazine and isosorbide dinitrate Explanation: A combination of hydralazine and isosorbide dinitrate may be an alternative for clients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.

The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply. Numbness and tingling in the extremities Diuresis Bradycardia Shortness of breath Chest pain Confusion

Confusion Bradycardia Explanation: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.

The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options. Due to the client's high risk for developing Select... as a result of the prescribed medication, the nurse focuses on monitoring the client for Select...

Due to the client's high risk for developing -hypokalemia as a result of the prescribed medication, the nurse focuses on monitoring the client for -ventricular arrhythmia Explanation: Furosemide, a loop diurectic, is often prescribed for clients who experience fluid volume overload due to a diagnosis of heart failure (HF). The client who is newly prescribed furosemide for the treatment of hypervolemia due to HF is at a high risk for developing fluid and electrolyte abnormalites, with a high risk for hypokalemia. Hypokalemia is a potentially life-threatening complication of loop diuretic therapy due to the risk for cardiac arrhythmias. When assessing a client for hypokalemia, the nurse monitors the client for ventricular arrhythmias. This is a priority in the provision of care for a client who is prescribed furosemide for the treatment of heart failure. Although hyponatremia and hyperuricemia are both potential side effects associated with diuretic therapy, they are not high r

The diagnosis of heart failure is usually confirmed by which of the following?

Echocardiogram Explanation: Although the chest X-ray can indicate cardiomegaly and the ECG can indicate a left ventricular abnormality, it is the echocardiogram that is diagnostic. This test measures ejection fraction (EF) which, if greater than 40% and accompanied with signs and symptoms of heart failure, indicates diastolic dysfunction and impaired ventricular relaxation.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Blood urea nitrogen (BUN) Echocardiogram Serum electrolytes Electrocardiogram (ECG)

Echocardiogram Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Electrocardiogram (ECG) Blood urea nitrogen (BUN) Serum electrolytes Echocardiogram

Echocardiogram Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? -Electrocardiogram (ECG) -Blood urea nitrogen (BUN) -Serum electrolytes -Echocardiogram

Echocardiogram Explanation: An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.

An older adult client with heart failure is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this client's subsequent care, what nursing concern should be identified? Altered tissue perfusion risk related to arrhythmia Altered breathing pattern risk related to hypoxia Falls risk related to hyp

Falls risk related to hypotension Explanation: The combination of low BP, diuretic use, and ACE inhibitor use constitutes a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The client's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all clients with heart failure, but this is not in evidence for this client at this time.

An older adult client with heart failure is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this client's subsequent care, what nursing concern should be identified? Excess fluid volume risk related to medication regimen Falls risk related to hypotension Altered tissue perfusion risk related

Falls risk related to hypotension Explanation: The combination of low BP, diuretic use, and ACE inhibitor use constitutes a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The client's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all clients with heart failure, but this is not in evidence for this client at this time.

The nurse visits the home of a client with heart failure. Which assessment finding indicates to the nurse that the client's tolerance to activity is deteriorating? Needs to use a scooter for shopping Weight loss of 0.5 kg (1.1 lbs.) Bilateral lower extremity edema +1 Fatigue after walking to answer the door

Fatigue after walking to answer the door Explanation: The client's response to activity needs to be monitored. If the client is at home, the degree of fatigue felt after the activity can be used to assess the response. Weight loss is not used to assess activity tolerance but would be helpful to determine the response to medication therapy. Lower extremity edema is not used to assess activity tolerance but would be helpful to determine the response to medication therapy. Tolerance to exercise would be assessed by monitoring heart rate, which should return to baseline within 3 minutes after the activity. Since the client's heart rate returned to baseline in 2 minutes, the activity is being tolerated. Use of a motorized scooter for shopping would not be the best indicator of exercise and/or activity tolerance.

Which medication is categorized as a loop diuretic? Furosemide Spironolactone Chlorothiazide Chlorthalidone

Furosemide Explanation: Furosemide is commonly used to treat cardiac failure. Loop diuretics inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Chlorothiazide and chlorthalidone are categorized as thiazide diuretics. Spironolactone is categorized as a potassium-sparing diuretic.

The nurse is performing an initial assessment of a client diagnosed with heart failure (HF) that includes the client's sensorium and level of consciousness (LOC). Why is the assessment of the client's sensorium and LOC important in clients with HF? -HF ultimately affects oxygen transportation to the brain. -Clients with HF are susceptible to overstimulation of the sympathetic nervous system. -The most significant adverse effect of medications used for HF treatment is altered LOC. -Decrease

HF ultimately affects oxygen transportation to the brain. Explanation: As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in clients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular (CV). Reference:

A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure? Hypertension in older males regularly leads to heart failure. Hypertension causes the heart's chambers to shrink. Heart failure occurs when blood pressures drops. Hypertension causes the heart's chambers to enlarge and weaken.

Hypertension causes the heart's chambers to enlarge and weaken. Explanation: Hypertension causes the heart's chambers to enlarge and weaken, making it impossible for the ventricles to eject all the blood they receive.

The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with ordinary physical activity. Under what classification does the nurse understand this patient would be categorized? III II IV I

II Explanation: Classification II of heart failure is indicated by the patient being comfortable at rest, but experiencing fatigue, palpitation, or dyspnea during ordinary physical activity.

The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with ordinary physical activity. Under what classification does the nurse understand this patient would be categorized? III IV II I

II Explanation: Classification II of heart failure is indicated by the patient being comfortable at rest, but experiencing fatigue, palpitation, or dyspnea during ordinary physical activity.

Which New York Heart Association classification of heart failure (HF) has a poor prognosis and includes symptoms of cardiac insufficiency at rest? III IV I II

IV Explanation: Symptoms of cardiac insufficiency at rest are classified as IV according to the New York Heart Association Classification of HF. In Class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In Class II, there is a slight limitation of ADLs. In Class III, there is marked limitation of activities of daily living (ADLs).

A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client? In a high Fowler position In a flat, supine position On the left side-lying position In the Trendelenburg position

In a high Fowler position Explanation: Proper positioning can help reduce venous return to the heart. The client is positioned upright. If the client is unable to sit with the lower extremities dependent, the client may be placed in an upright position in bed. The supine and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying position does not promote circulation.

The nurse is caring for a client with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. Which medical intervention can be performed that may extend the survival of the client? Administration of a beta-blocker Insertion of an implantable pacemaker Administration of a calcium channel blocker Insertion of an implantable cardioverter defibrillator (ICD)

Insertion of an implantable cardioverter defibrillator (ICD) Explanation: In clients with severe left ventricular dysfunction and the possibility of life-threatening dysrhythmias, placement of an implantable cardioverter defibrillator (ICD) can prevent sudden cardiac death and extend survival. A pacemaker, a calcium-channel blocker, and a beta-blocker are not medical interventions that may extend the survival of the client with left ventricular dysfunction.

A patient has been newly diagnosed with heart failure (HF) and has come to the meet with the nurse at the clinic for health education. What lifestyle recommendation should the nurse provide to this patient when discussing dietary modifications? "It's in your best interests to avoid excessive fluids and sodium in your diet." "Try to replace as many of the complex carbohydrates in your diet with simple sugars." "I'll teach you some good sources of potassium, which you should try to

It's in your best interests to avoid excessive fluids and sodium in your diet." Explanation: Lifestyle recommendations for the management of HF include restriction of dietary sodium; avoidance of excessive fluid intake, alcohol, and smoking; weight reduction when indicated; and regular exercise. It is unnecessary to increase potassium intake, replace complex carbohydrates, or eat frequent, smaller meals.

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? JVD is noted 4 cm above the sternal angle. JVD is noted 2 cm above the sternal angle. JVD is noted at the level of the sternal angle. No JVD is present.

JVD is noted 4 cm above the sternal angle. Explanation: JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

Which is a characteristic of right-sided heart failure? Dyspnea Pulmonary crackles Cough Jugular vein distention

Jugular vein distention Explanation: Jugular vein distention is a characteristic of right-sided heart failure. Dyspnea, pulmonary crackles, and cough are manifestations of left-sided heart failure.

Which is the hallmark of heart failure? Pulmonary congestion Limited ADLs Basilar crackles Low ejection fraction (EF)

Low ejection fraction (EF) Explanation: Although a low EF is a hallmark of heart failure (HF), the severity of HF is frequently classified according to the client's symptoms. Pulmonary congestion, limitation of ADLs, and basilar crackles are all symptoms of HF.

The nurse is providing discharge teaching to a patient diagnosed with heart failure. What should the nurse teach this patient to do to monitor fluid balance? Assess radial pulses. Monitor bowel movements Monitor blood pressure. Monitor weight daily.

Monitor weight daily. Explanation: Daily weights at the same time every day can be a good indicator of fluid balance. Assessing radial pulses and monitoring the blood pressure may be done, but they do not provide information about fluid balance.

The nurse is educating an older adult client diagnosed with heart failure (HF) about the prescribed medication regimen. Which will the nurse educate this client about the use of oral diuretics? Avoid taking the diuretic within 2 hours of consuming dairy products. Oral diuretics are used with other prescribed medications. Avoid drinking fluids for 2 hours after taking the diuretic. Take the diuretic only on days when experiencing shortness of breath.

Oral diuretics are used with other prescribed medications. Explanation: Diuretics should never be used alone to treat HF because they don't prevent further myocardial damage and are used to improve symptoms. The nurse would not teach the client about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated. The client would not only take the diuretic on days when experiencing shortness of breath.

A patient in cardiogenic shock after a myocardial infarction is placed on an intra-aortic balloon pump (IABP). What does the nurse understand is the mechanism of action of the balloon pump? The balloon inflates at the beginning of diastole and deflates before systole to augment the pumping action of the heart. The balloon delivers an electrical impulse to correct dysrhythmias the patient experiences. The balloon will inflate at the beginning of systole and deflate before diastole to provid

The balloon inflates at the beginning of diastole and deflates before systole to augment the pumping action of the heart. Explanation: The IABP uses internal counterpulsation through the regular inflation and deflation of the balloon to augment the pumping action of the heart. It inflates during diastole, increasing the pressure in the aorta during diastole and therefore increasing blood flow through the coronary and peripheral arteries. It deflates just before systole, lessening the pressure within the aorta before left ventricular contraction, decreasing the amount of resistance the heart has to overcome to eject blood and therefore decreasing left ventricular workload.

What is the main difference between Class I and Class II heart failure as defined by the New York Heart Association (NYHA)? Duration of symptoms The client is unable to carry out any physical activity. There is a marked limitation of physical activity. The level of physical activity each allows

The level of physical activity each allows Explanation: Both Class I and Class II levels of heart failure are considered Mild under the New York Heart Association (NYHA) guidelines. The difference is that in Class II, the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea, whereas in Class I, the client is comfortable both at rest and during ordinary physical activity. A marked limitation of physical activity would be a sign of Moderate heart failure, and inability to carry out any physical activity is a sign of Severe heart failure.

A client taking an ACE inhibitor has developed a dry, hacking cough. Because of this side effect, the client no longer wants to take that medication. What medication that has similar hemodynamic effects does the nurse anticipate the health care provider ordering? Isosorbide dinitrate Furosemide Metoprolol Valsartan

Valsartan Explanation: If the patient cannot continue taking an angiotensin-converting enzyme (ACE) inhibitor because of development of cough, an elevated creatinine level, or hyperkalemia, an angiotensin receptor blocker (ARB) or a combination of hydralazine and isosorbide dinitrate is prescribed (see Table 29-3).

The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer? Valsartan (Diovan) Carvedilol (Coreg) Digoxin (Lanoxin) Metolazone (Zaroxolyn)

Valsartan (Diovan) Explanation: Valsartan (Diovan) is the only angiotensin receptor blocker listed. Digitalis/digoxin (Lanoxin) is a cardiac glycoside. Metolazone (Zaroxolyn) is a thiazide diuretic. Carvedilol (Coreg) is a beta-adrenergic blocking agent (beta-blocker).

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? Weighing the client daily at the same time each day Checking the client's lungs for crackles during every shift Assessing the client's vital signs every 4 hours Assessing for peripheral edema

Weighing the client daily at the same time each day Explanation: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

Which nursing intervention should the nurse perform when a client with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta-blockers? Withhold the drug and inform the primary health care provider. Continue the drug and document in the client's chart. Check for signs of toxicity. Observe for symptoms of pulmonary edema.

Withhold the drug and inform the primary health care provider. Explanation: Before administering a beta-blocker, the nurse should monitor the client's apical pulse. If the heart rate is less than 60 bpm, the nurse should withhold the drug and inform the primary health care provider.

A client has been diagnosed with congestive heart failure. This client's cardiac function has been compromised since the client suffered a myocardial infarction 3 years ago. Heart failure is classified by: length of disability post-MI. using the New York Heart Association scale. severity of the MI. amount of activity restriction the failure imposes.

amount of activity restriction the failure imposes. Explanation: Chronic heart failure is classified based on the amount of activity restriction it imposes. Although organizations that develop the classifications may have varying stages, they are all based on the level of activity restriction.

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure? ascites weight loss resting bradycardia warm extremities

ascites Explanation: Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, ascites, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough. Mixed heart failures can have all symptoms of right and left plus cool extremities, resting tachycardia, and weight gain.

A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)? decrease in renal perfusion increased blood volume ejected from ventricle vasodilation of skin dehydration

decrease in renal perfusion Explanation: A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.

The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema? increased right atrial resistance increased left atrial contractility decreased left ventricular pumping decreased right ventricular elasticity

decreased left ventricular pumping Explanation: Pulmonary edema is an acute event that results from heart failure. Myocardial scarring, resulting from ischemia, limits the distensibility of the ventricle, making it vulnerable to demands for increased workload. When the demand on the heart increases, there is resistance to left ventricular filling and blood backs up into the pulmonary circulation. Pulmonary edema quickly develops.

The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs? furosemide metoprolol dopamine enalapril

dopamine Explanation: Dopamine, a sympathomimetic drug, is used to treat cardiogenic shock. It increases perfusion pressure to improve myocardial contractility and blood flow through vital organs. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and doesn't have a direct effect on contractility or tissue perfusion. Metoprolol is a beta-adrenergic blocker that slows heart rate and lowers blood pressure, undesirable effects when treating cardiogenic shock.

Frequently, what is the earliest symptom of left-sided heart failure? anxiety confusion chest pain dyspnea on exertion

dyspnea on exertion Explanation: Dyspnea on exertion is often the earliest symptom of left-sided heart failure.

The nurse is assessing a newly admitted client with chest pain. What medical disorder is most likely causing the client to have jugular vein distention? pneumothorax abdominal aortic aneurysm myocardial infarction (MI) heart failure

heart failure Explanation: Elevated venous pressure, exhibited as jugular vein distention, indicates the heart's failure to pump. Jugular vein distention isn't a symptom of abdominal aortic aneurysm or pneumothorax. If severe enough, an MI can progress to heart failure, but an MI alone doesn't cause jugular vein distention.

The nurse is receiving a client from the emergency in cardiogenic shock. What mechanical device does the nurse anticipate will be inserted into the client? intra-aortic balloon pump hypothermia-hyperthermia machine cardiac pacemaker defibrillator

intra-aortic balloon pump Explanation: Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. The intra-aortic balloon pump increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate. Hypothermia-hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for termination of life-threatening ventricular rhythms.

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival? cholestyramine bumetanide diltiazem lisinopril

lisinopril Explanation: Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, beta-blockers, and diuretics such as bumetanide. Many of these medications, particularly ACE inhibitors and beta-blockers, improve symptoms and extend survival. Others, such as diuretics, improve symptoms but may not affect survival. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival? lisinopril bumetanide cholestyramine diltiazem

lisinopril Explanation: Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, beta-blockers, and diuretics such as bumetanide. Many of these medications, particularly ACE inhibitors and beta-blockers, improve symptoms and extend survival. Others, such as diuretics, improve symptoms but may not affect survival. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival? lisinopril diltiazem bumetanide cholestyramine

lisinopril Explanation: Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, beta-blockers, and diuretics such as bumetanide. Many of these medications, particularly ACE inhibitors and beta-blockers, improve symptoms and extend survival. Others, such as diuretics, improve symptoms but may not affect survival. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.

A client has been rushed to the ED with pulmonary edema and is going to need oxygen immediately. Which oxygen delivery system should be used first? mechanical ventilation intubation mask nasal cannula

mask Explanation: Because pulmonary edema can be fatal, lung congestion needs to be relieved as quickly as possible. Supplemental oxygen is one of the first tools used to fight pulmonary edema. A mask, rather than nasal cannula, is needed to deliver the maximum percentages of oxygen. Intubation is reserved for when respiratory failure occurs. Mechanical ventilation is applied once respiratory failure occurs.

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client? Enlargement of joints Flexion contractures Vasculitis nausea and vomiting

nausea and vomiting Explanation: Digitalis medications are potent and may cause various toxic effects. The nurse should monitor the client for signs of digitalis toxicity, not just during the initial period of therapy, but throughout care management. The most common signs and symptoms include nausea and vomiting which can lead to dehydration and electrolyte imbalance. Symptoms of toxicity do not include vasculitis, flexion contractures, or enlargement of joints.

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client? nausea and vomiting Vasculitis Flexion contractures Enlargement of joints

nausea and vomiting Explanation: Digitalis medications are potent and may cause various toxic effects. The nurse should monitor the client for signs of digitalis toxicity, not just during the initial period of therapy, but throughout care management. The most common signs and symptoms include nausea and vomiting which can lead to dehydration and electrolyte imbalance. Symptoms of toxicity do not include vasculitis, flexion contractures, or enlargement of joints.

When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating -dyspnea upon exertion. -paroxysmal nocturnal dyspnea. -orthopnea. -hyperpnea.

orthopnea. Explanation: Clients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler position. Dyspnea upon exertion refers to difficulty breathing with activity. Hyperpnea refers to increased rate and depth of respiration. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Left-sided heart failure results in several symptoms due to reduced cardiac output. Which symptom would NOT contribute to a diagnosis of heart failure? moist crackles diminished urine output rapid pulse polydipsia

polydipsia Explanation: Exertional dyspnea is frequently the initial symptom. Orthopnea and paroxysmal nocturnal dyspnea may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Pulse may be rapid or irregular. BP may be elevated from sympathetic nervous system stimulation. A cough, hemoptysis, and moist crackles on auscultation are typical respiratory findings. Urine output is diminished.

A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of pneumonia. pulmonary edema. myocardial infarction. pulmonary embolism.

pulmonary embolism. Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of pulmonary embolism. myocardial infarction. pneumonia. pulmonary edema.

pulmonary embolism. Explanation: Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

A nurse suspects that a client has digoxin toxicity. The nurse should assess for: hearing loss. decreased urine output. vision changes. gait instability.

vision changes. Explanation: Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.

A client was admitted to the cardiac ICU with full-blown pulmonary edema. After treatment, the nurse discusses the client's symptoms with the client. A typical, subtle symptom that communicates right-sided heart failure is gradual, unexplained: None of the options is correct. weight loss cough weight gain

weight gain Explanation: The client with right-sided heart failure may have a history of gradual, unexplained weight gain, not weight loss, from fluid retention. Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area.

A client was admitted to the cardiac ICU with full-blown pulmonary edema. After treatment, the nurse discusses the client's symptoms with the client. A typical, subtle symptom that communicates right-sided heart failure is gradual, unexplained: weight loss weight gain None of the options is correct. cough

weight gain Explanation: The client with right-sided heart failure may have a history of gradual, unexplained weight gain, not weight loss, from fluid retention. Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area.

A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor? fluid intake and output. weight. vital signs. urine specific gravity.

weight. Explanation: Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.