Week 2: Ch 34

A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate? A. Because you have diabetes, you would not be a candidate for a heart transplant. B. The choice of a patient for a heart transplant depends on many different factors. C. Your heart failure has not reached the stage in which heart transplants are needed. D. People who have heart transplants are at risk for multiple complications after surgery.

B. The choice of a patient for a heart transplant depends on many different factors. Indications for a heart transplant include end-stage heart failure (Stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patients question.

An older adult patient with chronic heart failure (HF) and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed to continue at home. What is the best response by the nurse? A. "The medication prevents blood clots from forming in your heart." B. "The medication dissolves clots that develop in your coronary arteries." C. "The medication reduces clotting by decreasing serum potassium levels." D. "The medication increases your heart rate so that clots do not form in your heart."

A. "The medication prevents blood clots from forming in your heart." Chronic HF causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors.

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? A. A patient who is cool and clammy, with new-onset confusion and restlessness B. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. C. A patient who had dizziness after receiving the first dose of captopril (Capoten) D. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

A. A patient who is cool and clammy, with new-onset confusion and restlessness The patient who has wet-cold clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.

The nurse is preparing to administer a nitroglycerin patch to a patient. When providing teaching about the use of the patch, what should the nurse include? A. Avoid drugs to treat erectile dysfunction. B. Increase diet intake of high-potassium foods. C. Take an over-the-counter H2-receptor blocker. D. Avoid nonsteroidal antiinflammatory drugs (NSAIDS).

A. Avoid drugs to treat erectile dysfunction. The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. NSAIDs do not pose a risk in combination with nitrates. There is no need to take an H2-receptor blocker or increase the dietary intake of high-potassium foods.

Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? A. Monitor blood pressure frequently. B. Encourage patient to ambulate in room. C. Titrate nesiritide slowly before stopping. D. Teach patient about home use of the drug.

A. Monitor blood pressure frequently. Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Because the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in a home setting.

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to acute decompensated heart failure (ADHF)? A. Take medications as prescribed. B. Use oxygen when feeling short of breath. C. Direct questions only to the health care provider. D. Encourage most activity in the morning when rested.

A. Take medications as prescribed. The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF.

During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of feeling too tired to get out of bed. Based on these data, the best nursing diagnosis for the patient is: A. activity intolerance related to fatigue. B. disturbed body image related to weight gain. C. impaired skin integrity related to ankle edema. D. impaired gas exchange related to dyspnea on exertion.

A. activity intolerance related to fatigue. The patients statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems.

A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurses priority action will be to: A. give IV morphine sulfate 4 mg. B. give IV diazepam (V alium) 2.5 mg. C. increase nitroglycerin (Tridil) infusion by 5 mcg/min. D. increase dopamine (Intropin) infusion by 2 mcg/kg/min.

A. give IV morphine sulfate 4 mg. Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What is the priority action by the nurse? A. Withhold the daily dose until the following day. B. Withhold the dose and report the potassium level. C. Give the digoxin with a salty snack, such as crackers. D. Give the digoxin with extra fluids to dilute the sodium level.

B. Withhold the dose and report the potassium level. The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and wait for the potassium level to normalize. The provider may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? A. Auscultate the abdomen. B. Check the capillary refill. C. Auscultate the breath sounds. D. Assess the level of orientation.

C. Auscultate the breath sounds. This patients severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patients volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%? A. Need to begin an aerobic exercise program several times weekly B. Use of salt substitutes to replace table salt when cooking and at the table C. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors D. Importance of making an annual appointment with the primary care provider

C. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? A. Urine output B. Lung sounds C. Blood pressure D. Respiratory rate

C. Blood pressure Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? A. 2+ pedal edema B. Heart rate of 56 beats/minute C. Blood pressure (BP) of 88/42 mm Hg D. Complaints of fatigue

C. Blood pressure (BP) of 88/42 mm Hg The patients BP indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of b-adrenergic blockade, but the rate of 56 is not unusual with - adrenergic blocker therapy. b-Adrenergic blockade initially will worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? A. I will be sure to take the medication with food. B. I will need to eat more potassium-rich foods in my diet. C. I will call for help when I need to get up to use the bathroom. D. I will expect to feel more short of breath for the next few days.

C. I will call for help when I need to get up to use the bathroom. Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of b-adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

The nurse is administering a dose of Digitalis (digoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom? A. Muscle aches B. Constipation C. Loss of appetite D. Pounding headache

C. Loss of appetite Anorexia, nausea, vomiting, blurred or yellow vision, and dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Assess the IV insertion site for signs of extravasation. B. Teach the patient the reasons for remaining on bed rest. C. Monitor the patient's blood pressure and heart rate every hour. D. Titrate the rate to keep the systolic blood pressure >90 mm Hg.

C. Monitor the patient's blood pressure and heart rate every hour. An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, making adjustments to the drip rate for vasoactive medications, and monitoring for serious complications such as extravasation require RN level education and scope of practice.

After having a myocardial infarction (MI), the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108 beats/min. What should the nurse suspect is happening? A. Chronic HF B. Left-sided HF C. Right-sided HF D. Acute decompensated HF

C. Right-sided HF An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

The nurse prepares to administer digoxin 0.125 mg to a patient admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication? A. Prothrombin time B. Urine specific gravity C. Serum potassium level D. Hemoglobin and hematocrit

C. Serum potassium level Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity. Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit would not require holding the digoxin dose.

IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops: A. ventricular ectopy. B. a dry, hacking cough. C. a systolic BP <90 mm Hg. D. a heart rate <50 beats/minute.

C. a systolic BP <90 mm Hg. Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurses priority action will be to: A. have the patient recall the dietary intake for the last 3 days. B. ask the patient about the use of the prescribed medications. C. assess the patient for clinical manifestations of acute heart failure. D. teach the patient about the importance of restricting dietary sodium.

C. assess the patient for clinical manifestations of acute heart failure. The 5-pound weight gain over 3 days indicates that the patients chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse knows this finding indicates: A. decreased fluid volume. B. jugular vein atherosclerosis. C. increased right atrial pressure. D. incompetent jugular vein valves.

C. increased right atrial pressure. The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include: A. limit dietary sources of potassium. B. take the hydrochlorothiazide before bedtime. C. notify the health care provider if nausea develops. D. skip the digoxin if the pulse is below 60 beats/minute.

C. notify the health care provider if nausea develops. Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

A patient who has chronic heart failure tells the nurse, I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating! The nurse will document this assessment finding as: A. orthopnea. B. pulsus alternans. C. paroxysmal nocturnal dyspnea. D. acute bilateral pleural effusion.

C. paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the water pill with the heart pill. When planning for the patients discharge the nurse will facilitate a: A. consult with a psychologist. B. transfer to a long-term care facility. C. referral to a home health care agency. D. arrangements for around-the-clock care.

C. referral to a home health care agency. The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patients home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care.

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? A. Weight loss of 2 pounds in 24 hours B. Hourly urine output greater than 60 mL C. Reduction in patient complaints of chest pain D. Reduced dyspnea with the head of bed at 30 degrees

D. Reduced dyspnea with the head of bed at 30 degrees Because the patients major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patients response.

When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include: A. canned and frozen fruits. B. fresh or frozen vegetables. C. eggs and other high-protein foods. D. milk, yogurt, and other milk products

D. milk, yogurt, and other milk products Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.

A patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? A. Review urinary output for the previous 24 hours. B. Restrict the patient's oral fluid intake to 500 mL/day. C. Assist the patient to a sitting position with arms on the overbed table. D. Teach the patient to use pursed-lip breathing until the dyspnea subsides.

C. Assist the patient to a sitting position with arms on the overbed table. The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.

A patient admitted with heart failure is anxious and reports shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety? (Select all that apply) A. Administer ordered morphine sulfate. B. Position patient in a semi-Fowler's position. C. Position patient on left side with head of bed flat. D. Instruct patient on the use of relaxation techniques. E. Use a calm, reassuring approach while talking to patient.

A, B, D, E Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)? A. How to take and record daily weight B. Importance of limiting aerobic exercise C. Date and time of follow-up appointment D. Symptoms indicating worsening heart failure E. Actions and side effects of prescribed medications

A, C, D, E The Joint Commission Core Measures state that patients should be taught about prescribed medications, follow-up appointments, weight monitoring, and actions to take for worsening symptoms. Patients with heart failure are encouraged to begin or continue aerobic exercises such as walking, while self-monitoring to avoid excessive fatigue.

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient? (Select all that apply) A. Left ventricular function is documented B. Controlling dysrhythmias will eliminate HF C. Prescription for digoxin (Lanoxin) at discharge D. Prescription for angiotensin-converting enzyme inhibitor at discharge E. Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

A, D, E The Joint Commission has identified these 3 core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.

At a clinic visit, the nurse provides dietary teaching for a patient recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement? A. "I will limit the amount of milk and cheese in my diet." B. "I can add salt when cooking foods but not at the table." C. "I will take an extra diuretic pill when I eat a lot of salt." D. "I can have unlimited amounts of foods labeled as reduced sodium."

A. "I will limit the amount of milk and cheese in my diet." Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt should not be added during food preparation or at the table. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake. Foods labeled as reduced sodium contain at least 25% less sodium than regular.

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? A. Oxygen saturation of 88% B. Weight gain of 1 kg (2.2 lb) C. Heart rate of 106 beats/minute D. Urine output of 50 mL over 2 hours

A. Oxygen saturation of 88% A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.

A patient with a history of chronic heart failure is hospitalized with severe dyspnea and a dry, hacking cough. Assessment findings include pitting edema in both ankles, BP 170/100 mmHg, pulse 92 bpm, and respirations 28. Which explanation, if made by the nurse, is most accurate? A. "The assessment indicates that venous return to the heart is impaired, causing a decrease in cardiac output." B. "The manifestations indicate impaired emptying of both the right and left ventricles, with decreased forward blood flow." C. "The myocardium is not receiving enough blood supply through the coronary arteries to meet its oxygen demand." D. "The patient's right side of the heart is failing to pump enough blood to the lungs to provide systemic oxygenation."

B. "The manifestations indicate impaired emptying of both the right and left ventricles, with decreased forward blood flow." The patient is experiencing acute decompensated heart failure with symptoms of both right- and left-sided heart failure. Left-sided heart failure prevents normal, forward blood flow and causes pulmonary congestion. Right-sided heart failure causes a back-up of blood and results in venous congestion.

A patient with left-sided heart failure is prescribed oxygen at 4 L/min via NC, furosemide (Lasix), spironolactone (Aldactone), and enalapril (Vasotec). Which assessment should the nurse complete to best evaluate the patient's response to the drugs? A. Observe skin turgor B. Auscultate lung sounds C. Measure blood pressure D. Review intake and output

B. Auscultate lung sounds Left-sided heart failure will prevent blood flow and will cause blood to back up into the left atrium and into the pulmonary veins. The increased pulmonary pressure causes fluid extravasation from the pulmonary capillary beds into the interstitial and then the alveoli, which manifests as pulmonary congestion and edema. The most important assessment to determine if the drugs are improving the patient's condition is to auscultate lung sounds. The other assessments are important but the best indicator of improvement of left ventricular function is a reduction in adventitious lung sounds (crackles).

What should the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure? A. Acute anxiety B. Hypotension and tachycardia C. Peripheral edema and weight gain D. Paroxysmal nocturnal dyspnea (PND)

B. Hypotension and tachycardia Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? A. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 B. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L C. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache D. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough

B. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L The patient's low potassium level increases the risk for digoxin toxicity and potentially fatal dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their medications, but their symptoms do not indicate potentially life-threatening complications.

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix). What outcome would demonstrate medication effectiveness? A. Promote vasodilation. B. Reduction of preload. C. Decrease in afterload. D. Increase in contractility.

B. Reduction of preload. Diuretics such as furosemide are used in the treatment of heart failure to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.

The home care nurse visits a patient with chronic heart failure. Which assessment findings would indicate acute decompensated heart failure (pulmonary edema)? A. Fatigue, orthopnea, and dependent edema B. Severe dyspnea and blood-streaked, frothy sputum C. Temperature is 100.4° F and pulse is 102 beats/min D. Respirations 26 breaths/min despite oxygen by nasal cannula

B. Severe dyspnea and blood-streaked, frothy sputum Manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths/min, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? A. Serum troponin B. Arterial blood gases C. B-type natriuretic peptide D. 12-lead electrocardiogram

C. B-type natriuretic peptide B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A twelve-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? A. Presence of 1 to 2+ edema in the feet and ankles B. Palpable liver edge 2 cm below the ribs on the right side C. Serum potassium level 3.0 mEq/L after 1 week of therapy D. Weight increase from 120 pounds to 122 pounds over 3 days

C. Serum potassium level 3.0 mEq/L after 1 week of therapy Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patients heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that: A. she will take furosemide (Lasix) every day at bedtime. B. the nitroglycerin patch is applied when any chest pain develops. C. she will call the clinic if her weight goes from 124 to 128 pounds in a week. D. an additional pillow can help her sleep if she is feeling short of breath at night.

C. she will call the clinic if her weight goes from 124 to 128 pounds in a week. Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an as needed basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by further elevating the head of the bed.

An asymptomatic patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before dangling the patient on the bedside, what should the nurse assess first? A. Urine output B. Heart rhythm C. Breath sounds D. Blood pressure

D. Blood pressure The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas exchange.

A patient is scheduled for a heart transplant. What is a major cause of death beyond the first year after a heart transplant? A. Infection B. Acute rejection C. Immunosuppression D. Cardiac vasculopathy

D. Cardiac vasculopathy Beyond the first year after a heart transplant, cancer (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient's risk of an infection.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? A. Furosemide (Lasix) 60 mg B. Captopril (Capoten) 25 mg C. Digoxin (Lanoxin) 0.125 mg D. Carvedilol (Coreg) 3.125 mg

D. Carvedilol (Coreg) 3.125 mg Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other medications are appropriate for the patient with ADHF.

A patient with a long-standing history of heart failure recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? A. Taper the patient off his current medications. B. Continue education for the patient and his family. C. Pursue experimental therapies or surgical options. D. Choose interventions to promote comfort and prevent suffering.

D. Choose interventions to promote comfort and prevent suffering. The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not used in the care of hospice patients.

Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about: A. digitalis preparations. B. b-adrenergic blockers. C. calcium channel blockers. D. angiotensin-converting enzyme (ACE) inhibitors.

D. angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and b-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The b- adrenergic blockers are not used as initial therapy for new onset heart failure.