Ch. 34 - Heart Failure

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/min

c. a systolic BP <90 mm Hg rationale: sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension

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 rationale: 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.

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 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. how to take and record daily weight C. date and time of follow up appointment D. symptoms indicating worsening heart failure E. actions and side effects of prescribed medications

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 (2.2lb) c. heart rate of 106 d. urine output of 50 mL over 2 hours

a. oxygen sat of 88% rationale: a decrease in oxygen saturation to less than 92% indicates hypoxemia. the nurse should administer supplemental oxygen immediately.

The nurse is caring for a patient who is receiving IV furesemide (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 bas 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 the bed at 30 degrees

d. reduced dyspnea with the head of bed at 30 degrees rationale: 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

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 rationale: b-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as the do with heart failure.

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 rationale: The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management.

During a visit to a 78 yr 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 rationale: the patients statement supports the diagnosis of activity intolerance.

A patient in the ICU with acute decompensated heart failure complains of severe dyspnea and is anxious, tachypeanic, 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 (Valium) 2.5 mg c. increase nitroglycerin (Tidril) infusion by 5 mcg/min. d. increase dopamine (intropin) infusion by 2 mcg/min

a. give IV morphine sulfate 4 mg rationale: 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.

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. rationale: nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension.

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 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 rationale: the patients low potassium level increases the risk for digoxin toxicity and potentially fatal dysrhythmias.

A 53 yr 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 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. rationale: 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.

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 HCP. a. 2+ pedal edema b. heart rate of 56 beats/min c. BP of 88/42 d. complains of fatigue

c. BP of 88/42 mm Hg. rationale: the patients BP indicates that the dose of metoprolol may beed to be decreased because of hypotension.

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 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. rationale: 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.

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 rationale: Hypokalemia can predispose the patient to life-threatening dysrhythmias and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which can also cause life threatening dysrhythmias.

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 rationale: the 5 pound weight gain over the 3 days indicates that the patients chronic heart failure may be worsening.

A patient with a history of chronic heart failure is admitted to the ED with severe dyspnea and a dry, hacking cough. Which action should the nurse do first a. Auscultate the abdomen b. Check the cap refill c. auscultate the breath sounds d. Assess the level of orientation

c. auscultate the breath sounds rationale: the patients severe dyspnea and cough indicate that acute decompensated heart failure is occurring.

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. rationale: 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 progression of heart failure.

While assessing a 68 yr 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 rationale: 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.

A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure has the following nursing interventions included in the plan of care. Which action will be most appropriate for the RN to delegate to an experienced 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 patients blood pressure and heart rate every hour. d. titrate the rate to keep the systolic blood pressure >90 mm Hg.

c. monitor the patients blood pressure and heart rate every hour. rationale: an experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hyprochlorothiazide (HydroDIRUIL). Appropriate instructions for the patient include. a. Limit dietary sources of potassium b. take the hydrochlorothiazide before bedtime c. notify the HCP if nausea develops d. skip the digoxin if the pulse is below 60 beats/min

c. notify the HCP if nausea develops. rationale: Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the dose, if necessary

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 bilarteral pleural effusion

c. paroxysmal nocturnal dyspnea rationale: 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

While admitting an 82 yr 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 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 rationale: the data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed.

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 SOB at night.

c. she will call the clinic if her weight goes from 124 to 128 pounds in a week rationale: teaching for a patient with heart failure includes information about the need to weigh daily and notify the HCP about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week.

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 rationale: Although carbedilol 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.

Following an acute myocardial infarction, a previously healthy 63 yr 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 rationale: ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a MI and as a first line therapy for patients with CHF.