N355 Ch. 29: Management of Patients With Complications from Heart Disease
The client with cardiac failure is taught to report which symptom to the health care provider or clinic immediately? -Increased appetite -Ability to sleep through the night -Weight loss -Persistent cough
Correct Answer: Persistent cough Explanation: Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite, weight gain, interrupted sleep, unusual shortness of breath, and increased swelling should also be reported immediately. p. 832
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'm having trouble going up the steps during the day." -"I eat six small meals a day when I am hungry." -"I've stopped eating foods with salt, though I miss the taste."
Correct response: "I'm having trouble going up the steps during the day." Explanation: Difficulty with activities 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. p. 829
A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered? -An echocardiogram -A chest x-ray -A ventriculogram -An electrocardiogram
Correct response: An echocardiogram Explanation: Increasing shortness of breath (dyspnea) and fatigue are common signs of left-sided heart failure (HF). However, some of the physical signs that suggest HF may also occur with other diseases, such as renal failure and chronic obstructive pulmonary disease; therefore, diagnostic testing is essential to confirm a diagnosis of HF. Assessment of ventricular function is an essential part of the initial diagnostic workup. An echocardiogram is usually performed to determine the ejection fraction, identify anatomic features such as structural abnormalities and valve malfunction, and confirm the diagnosis of HF. p.819
The nurse is teaching a group of clients with heart failure about how to decrease leg edema. What dietary advice will the nurse give to clients with severe heart failure? -Encourage increased intake of red meat. -Avoid the intake of canned fruit and fruit juices. -Encourage increased intake of vegetables with natural sodium. -Avoid the intake of processed and commercially prepared foods.
Correct response: Avoid the intake of processed and commercially prepared foods. Explanation: Until edema resolves, a client with severe heart failure requires restriction of sodium to 500 to 1,000 mg/day. Therefore, processed and commercially prepared foods are eliminated. Vegetables with natural sodium, for example, beets, carrots, and "greens," should be avoided. Fresh, frozen, and canned fruit and fruit juices are not restricted. Increased intake of red meat should not be encouraged; it should be restricted to 6 oz per day. p. 832
The nursing instructor is teaching their clinical group how to assess a client for congestive heart failure. How would the instructor teach the students to assess a client with congestive heart failure for nocturnal dyspnea? -By measuring the client's abdominal girth -By questioning how many pillows the client normally uses for sleep -By collecting the client's urine output -By observing the client's diet during the day
Correct response: By questioning how many pillows the client normally uses for sleep Explanation: The nurse should ask the client about nocturnal dyspnea by questioning how many pillows the client normally uses for sleep. This is because being awakened by breathlessness may prompt the client to use several pillows in bed. Collecting the client's urine output, observing the client's diet, or measuring the client's abdominal girth does not help assess for nocturnal dyspnea. p.822
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. -Calculate the client's intake and output. -Check the client's potassium level.
Correct response: 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. p. 824
A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved? -Increase in CVP -Decrease in blood pressure -Absence of cough -Decrease in central venous pressure (CVP)
Correct response: Decrease in central venous pressure (CVP) Explanation: A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade. p. 836
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? -Decreased urinary output -Hypotension -Dyspnea on exertion -Tachycardia
Correct response: Dyspnea on exertion Explanation: Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia. p. 822
The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action? -Elevate the head of the bed. -Notify the family of a change in condition. -Report a decrease in urine output. -Assess pulse oximetry reading.
Correct response: Elevate the head of the bed. Explanation: The nurse's priority action is to elevate the head of bed to help with breathing. The pulse oximetry reading provides more data, but is not the priority intervention. Reporting a decrease urine output is not a priority for the client. Notification of the family is not a priority to help with breathing. p. 834
Which medication is categorized as a loop diuretic? -Spironolactone -Chlorothiazide -Furosemide -Chlorthalidone
Correct response: 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. p. 825
A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload? -Head of the bed elevated 30 degrees and legs elevated on pillows -Head of the bed elevated 45 degrees and lower arms supported by pillows -Prone with legs elevated on pillows -Supine with arms elevated on pillows above the level of the heart
Correct response: Head of the bed elevated 45 degrees and lower arms supported by pillows Explanation: Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the client's weight on the shoulder muscles. p. 830
Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest? -I -II -III -IV
Correct response: IV Explanation: Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In class II, ADLs are slightly limited. In class III, ADLs are markedly limited. p. 819
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client? -Low-cholesterol diet -Low-potassium diet -Low-fat diet -Low-sodium diet
Correct response: Low-sodium diet Explanation: Medical management of both left-sided and right-sided heart failure is directed at reducing the heart's workload and improving cardiac output primarily through dietary modifications, drug therapy, and lifestyle changes. A low-sodium diet is prescribed, and fluids may be restricted. Because the client will be on a diuretic such as Lasix, he may become potassium depleted and would need potassium in the diet. A low-cholesterol and low-fat diet may be ordered but are not specific to the heart failure. p. 826
A nurse is assessing a client with suspected cardiac tamponade. How should the nurse assess the client for pulsus paradoxus? -Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally. -Measure the blood pressure in right arm as the client inhales slowly, then measure the blood pressure in the left arm as the client exhales slowly. -Measure blood pressure in either arm with the client holding his breath, then with the client breathing normally. -Measure blood pressure in the right arm, then in the left arm as the client slows the pace of his inhalations and exhalations.
Correct response: Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally. Explanation: To determine pulsus paradoxus, the nurse should measure blood pressure in either arm as the client slowly exhales and then as the client breathes normally. Unless the client has cardiac tamponade, the two measurements are usually less than 10 points apart. p. 836
A client has been diagnosed with heart failure. What is the major nursing outcome for the client? -Walk 30 minutes three times a week. -Reduce the workload on the heart. -Maintain a healthy diet. -Sleep 8 hours per night.
Correct response: Reduce the workload on the heart. Explanation: Specific objectives of medical management of heart failure include reducing the workload on the heart by reducing preload and afterload. The other choices are objectives that may be supportive of a healthy lifestyle, but are not specific to a client with heart failure. p. 829
A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure? -Left-sided heart failure -Chronic heart failure -Acute heart failure -Right-sided heart failure
Correct response: Right-sided heart failure Explanation: Signs and symptoms of Right Ventricular Failure include: Weakness; Ascites; Weight gain; Nausea, vomiting; Dysrhythmias; Elevated central venous pressure; Jugular vein distention. The scenario does not indicate whether the heart failure is chronic or acute. Therefore, options A, B, and C are incorrect. p.823
Which is a potassium-sparing diuretic used in the treatment of heart failure? -Ethacrynic acid -Spironolactone -Chlorothiazide -Bumetanide
Correct response: Spironolactone Explanation: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide diuretic. Bumetanide and ethacrynic acid are loop diuretics. p. 825
Which is a potassium-sparing diuretic used in the treatment of heart failure? -Spironolactone -Bumetanide -Chlorothiazide -Ethacrynic acid
Correct response: Spironolactone Explanation: Spironolactone is a potassium-sparing diuretic. Chlorothiazide is a thiazide diuretic. Bumetanide and ethacrynic acid are loop diuretics. p. 825
Which is a manifestation of right-sided heart failure? -Paroxysmal nocturnal dyspnea -Systemic venous congestion -Increase in forward flow -Accumulation of blood in the lungs
Correct response: Systemic venous congestion Explanation: Right-sided heart failure causes systemic venous congestion and a reduction in forward flow. Left-sided heart failure causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues. Some clients with left-sided heart failure get episodes of dyspnea at night, known as paroxysmal nocturnal dyspnea.
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? -The development of right-sided heart failure -The development of cor pulmonale -The development of chronic obstructive pulmonary disease (COPD) -The development of left-sided heart failure
Correct response: The development of left-sided heart failure Explanation: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage. p. 822
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? -The development of right-sided heart failure -The development of chronic obstructive pulmonary disease (COPD) -The development of left-sided heart failure -The development of cor pulmonale
Correct response: The development of left-sided heart failure Explanation: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage. p.822
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 -There is a marked limitation of physical activity. -The level of physical activity each allows -The client is unable to carry out any physical activity.
Correct response: 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. p. 819
The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided heart failure? -ascites -weight loss -warm extremities -resting bradycardia
Correct response: 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. p. 821-822
A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid: -canned peas. -ready-to-eat cereals. -dried peas. -angel food cake.
Correct response: canned peas. Explanation: There is a wide variety of foods that the client can still eat; the key is to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. It is important to read food labels and look for foods that contain less than 300 mg sodium/serving. p. 830
The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy? -decreased peripheral perfusion to the extremities -decreased left ventricular workload -decreased right ventricular workload -decreased renal perfusion
Correct response: decreased left ventricular workload Explanation: The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The therapeutic effect is decreased left ventricular workload. The IABP does not change right ventricular workload. The IABP increases perfusion to the coronary and peripheral arteries. The renal perfusion is not affected by IABP. p. 835
The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart? -echocardiogram -MRI -nuclear angiography -pulmonary arterial pressure
Correct response: echocardiogram Explanation: The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. An MRI, pulmonary arterial pressure, and nuclear angiography do not give diagnostic information about the heart's ejection fraction. p. 819
The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure? -furosemide -mannitol -metolazone -spironolactone
Correct response: furosemide Explanation: Loop diuretics such as furosemide, bumetanide, and torsemide are the preferred first-line diuretics because of their efficacy in patients with and without renal impairment. Spironolactone is a potassium diuretic. Mannitol is an osmotic diuretic not used for heart failure. Metolazone is a potassium diuretic not used for first treatment for heart failure. Diuretics should never be used alone to treat HF because they don't prevent further myocardial damage. p. 825
The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed? -heart transplant -ventricular access device -cardiac resynchronization therapy -implantable cardiac defibrillator (ICD)
Correct response: heart transplant Explanation: Heart transplantation involves replacing a person's diseased heart with a donor heart. This is an option for advanced HF patients when all other therapies have failed. A ventricular access device, ICD, and cardiac resynchronization therapy would be tried prior to a heart transplant. p.828
The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion? -hepatomegaly -ascites -inadequate cardiac output -nocturia
Correct response: inadequate cardiac output Explanation: Pulmonary congestion occurs and tissue perfusion is compromised and diminished when the heart, primarily the left ventricle, cannot pump blood out of the ventricle effectively into the aorta and the systemic circulation. Ascites is fluid in the abdomen, not a cause of congestion. Hepatomegaly is an enlarged liver, which does not cause crackling breath sounds. Nocturia, or voiding at night, does not cause crackling breath sounds. p. 818
When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating: -orthopnea. -dyspnea upon exertion. -hyperpnea. -paroxysmal nocturnal dyspnea.
Correct response: 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. p. 822
A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective? skin rash bradycardia postural hypotension peripheral edema
Correct response: peripheral edema Explanation: Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective. The individual will also most like experience trachycardia instead of bradycardia if the heart failure is worsening ang not responding to captopril. p.834
The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure? -decreased O2 saturation levels -oliguria -pitting edema -S4 ventricular gallop sign
Correct response: pitting edema Explanation: The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response. Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a thickened left ventricle, seen with aortic stenosis or hypertension. The decreased oxygen saturation levels are from hypoxemia. p. 823
A nurse suspects that a client has digoxin toxicity. The nurse should assess for: -hearing loss. -gait instability. -decreased urine output. -vision changes.
Correct response: 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. p. 826