Heart Failure (med-surg)
A patient in HF is started on beta-blockers. Because the risk of side effects of beta-blockers is so high, betablockers are started slowly and titrated slowly. What is an important nursing role during titration? a) Educating the patient about the potential of worsening symptoms during the early phase of treatment b) Stressing that improvement may not occur c) Educating the patient about optional medications d) Stressing that side effects can be incapacitating
ANSWER: A Rationale: An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks.
Patients with severe left ventricular dysfunction are at risk for sudden cardiac death. What medical intervention can be done that may extend the survival of the patient? a) Insertion of an implantable cardioverter defibrillator b) Insertion of an implantable pacemaker c) Begin a calcium channel blocker d) Begin a beta-blocker
ANSWER: A Rationale: In patients 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 patient with left ventricular dysfunction.
You are writing a teaching plan for a patient diagnosed with HF. What would be an important aspect to include in the teaching plan? a) Self-care b) Foot care c) Dressing changes d) Nutrition
ANSWER: A Rationale: Major goals for the patient may include promoting activity and reducing fatigue, relieving fluid overload symptoms, decreasing anxiety or increasing the patient's ability to manage anxiety, encouraging the patient to verbalize his or her ability to make decisions and influence outcomes, and teaching the patient about the self-care program. Nowhere in the scenario is there any indication that the patient needed teaching on foot care, dressing changes, or nutrition.
Which of the following actions is the appropriate initial response to a client coughing up pink, frothy sputum? a) Call for help b) Call the physician c) Start an IV line d) Suction the client
ANSWER: A Rationale: Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Because the client is at high risk for decompensation, the nurse should call for help but not leave the room. The other three interventions would immediately follow.
A patient admitted to the telemetry unit with heart failure is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How will the nurse position the patient? a) In an upright position in bed or with the legs dangling over the side of the bed b) On the left side in a supine position c) In a supine position on the back d) In a Trendelenburg position
ANSWER: A Rationale: Proper positioning can help reduce venous return to the heart. The patient is positioned upright, preferably with the legs dangling over the side of the bed. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion.
A nurse in the CCU is caring for a patient with heart failure who has developed an intracardiac thrombus. What is the most common complication of thromboembolic problems among HF patients? a) Pulmonary embolism b) Cerebral embolism c) Mesenteric embolism d) Peripheral embolism
ANSWER: A Rationale: Pulmonary embolism is the most common thromboembolic problem among patients with HF. Therefore options B, C, and D are incorrect.
Which of the following complications is indicated by a third heart sound (S3)? a) Ventricular dilation b) Systemic hypertension c) Aortic valve malfunction d) Increased atrial contractions
ANSWER: A Rationale: Rapid filling of the ventricle causes vasodilation that is auscultated as S3. Increased atrial contraction or systemic hypertension can result in S4. Aortic valve malfunction is heard as a murmur.
You have a patient diagnosed with systolic HF. What medications are routinely prescribed for systolic HF? a) Beta-blockers b) Calcium channel blockers c) Alpha agonists d) Angiotensin prohibiters
ANSWER: A Rationale: Several medications are routinely prescribed for systolic HF, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers are used only on patients with diastolic HF.
A patient with heart failure has several treatment options. What do the treatment options vary according to? a) The severity of the patient's condition b) The progression of the disease c) Whether there is pulmonary involvement d) Whether there is peripheral involvement
ANSWER: A Rationale: Treatment options vary according to the severity of the patient's condition and may include oral and IV medications, major lifestyle changes, supplemental oxygen, implantation of assistive devices, and surgical approaches, including cardiac transplantation. Therefore options B, C, and D are incorrect.
A patient has received educational information from the nurse about her diagnosis of heart failure. The patient has recognized that her HF can be successfully managed with lifestyle changes and medications. What does this recognition do for the patient? (Mark all that apply.) a) Lessens the number of recurrences of acute HF b) Increased life expectancy c) Use of medication increases d) Nutritional status decreases e) Unnecessary hospitalizations decrease
ANSWER: A, B, E
What signs and symptoms would a patient with left HF present with? Select all that apply. a) Bilateral crackles b) Tachycardia c) Chest pain d) Wheeze e) Shortness of breath
ANSWER: A, B, E
A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply. a) Ventricular hypertrophy b) Parasympathetic nervous stimulation c) Renin-angiotensin-aldosterone system d) Jugular venous distention e) Sympathetic nervous stimulation
ANSWER: A, C, E Rationale: When the heart begins to fail, the body activates three major compensatory systems: ventricular hypertrophy, the renin-angiotensin-aldosterone system, and sympathetic nervous stimulation. Parasympathetic stimulation and jugular venous distention are not compensatory mechanisms associated with heart failure.
A patient is placed on a low-sodium diet. Which statement by the patient indicates that the nurse's nutritional teaching plan has been effective? a) "I will have a ham and a cheese sandwich with potato chips for lunch." b) "I will have a baked potato with boiled chicken for dinner." c) "I will have a tossed salad with sardines and oil and vinegar dressing for lunch." d) "I will have chicken bouillon soup with crackers and an apple for lunch."
ANSWER: B
The nurse finds the apical impulse below the fifth intercostal space. The nurse suspects: a) Left atrial enlargement b) Left ventricular enlargement c) Right atrial enlargement d) Right ventricular enlargement
ANSWER: B Rationale: A normal apical pulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.
You are doing discharge teaching with a patient diagnosed with heart failure. What would you teach this patient about exercise? a) 15 minutes every day is good for you b) 30 minutes every day is good for you c) 45 minutes every day is good for you d) 1 hour every day is good for youANSWER: B Rationale: An acute illness that exacerbates HF symptoms or that requires hospitalization may be an indication for temporary bed rest. Otherwise, a total of 30 minutes of physical activity every day should be encouraged.
ANSWER: B Rationale: An acute illness that exacerbates HF symptoms or that requires hospitalization may be an indication for temporary bed rest. Otherwise, a total of 30 minutes of physical activity every day should be encouraged.
A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing which of the following? a) Dilated coronary arteries b) Increased myocardial contractility c) Decreased cardiac arrhythmias d) Decreased electrical conductivity in the heart
ANSWER: B Rationale: Digoxin is a cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat arrhythmias and does decrease the electrical conductivity of the myocardium, these are not primary reasons for its use in clients with heart failure and pulmonary edema.
Which assessment would be most appropriate for a patient who is receiving a loop diuretic for heart failure? a) Monitor liver function studies b) Monitor for hypotension c) Encourage the patient to spend time outdoors to aid in vitamin D absorption d) Restrict the intake of potassium
ANSWER: B Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension.
A client has a history of heart failure and has been taking several medications, including furosemide (Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first degree atrioventricular block. The nurse should assess the client for signs of which condition? a) Hyperkalemia b) Digoxin toxicity c) Fluid deficit d) Pulmonary edema
ANSWER: B Rationale: Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.
The nurse is teaching an 85-year-old patient diagnosed with HF about his medication. What would be especially important for the nurse to teach this patient about oral diuretics? a) Timing of fluid intake after taking medication b) Timing of medication administration c) Take them mid-afternoon d) Take them at night
ANSWER: B Rationale: Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patient's nighttime rest.
The client diagnosed with CHF is complaining of leg cramps at night. Which nursing intervention should be implemented? a) Check the client for peripheral edema and make sure the client takes a diuretic early in the day b) Monitor the client's potassium level and assess the client's intake of bananas and orange juice c) Determine if the client has gained weight and instruct the client to keep the legs elevated d) Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily
ANSWER: B Rationale: The most probable cause of the leg cramping is due to potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium.
The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms indicate: a) Pericarditis b) Heart failure c) Pulmonary edema d) Right ventricular hypertrophy
ANSWER: C
Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema? a) Risk for infection related to stasis of alveolar secretions b) Impaired skin integrity related to pressure c) Activity intolerance related to pump failure d) Constipation related to immobility
ANSWER: C
You are working as a triage nurse in the ED. A patient with HF has presented to the ED. In reviewing the patient's past medical history, what is the primary cause of the patient's HF? a) Type I diabetes b) Arteriosclerosis c) Atherosclerosis d) Pulmonary congestion
ANSWER: C Rationale: Atherosclerosis of the coronary arteries is the primary cause of HF.
A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to: a) Decrease circulatory overload b) Improve the myocardial workload c) Prevent thrombus formation d) Regulate cardiac rhythm
ANSWER: C Rationale: Coumadin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Coumadin does not reduce circulatory load or improve myocardial workload. Coumadin does not affect cardiac rhythm.
Which of the following symptoms might a client with right-sided heart failure exhibit? a) Adequate urine output b) Polyuria c) Oliguria d) Polydipsia
ANSWER: C Rationale: Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria.
Which of the following sets of conditions is an indication that a client with a history of left-sided heart failure is developing pulmonary edema? a) Distended jugular veins and wheezing b) Dependent edema and anorexia c) Coarse crackles and tachycardia d) Hypotension and tachycardia
ANSWER: C Rationale: Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia may occur due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right sided heart failure.
A nurse is monitoring a client receiving propranolol. Which of the following assessment would indicate a potential serious complication associated with propranolol? a) A baseline BP of 150/80 mmHg followed by a BP of 138/72 after two doses of the medication b) A baseline resting HR of 88bpm followed by a resting HR of 72bpm after two doses of the medication c) The development of audible expiratory wheezes d) The development of complaints of insomnia
ANSWER: D
The nursing instructor is teaching a pre-nursing pathophysiology class. The instructor is discussing heart failure. What assessment data, collected by the nurse, indicate an increase in a patient's risk for heart failure? a) Lasix 20 mg/day b) Potassium level of 5.7 mEq/L c) African-American man d) Age of 65 years or older
ANSWER: D Rationale: HF is the most common reason for hospitalization of people older than 65 years of age and is the second most common reason for visits to a physician's office. A potassium level of 5.7 mEq/L does not indicate an increased risk for HF. The fact that the patient takes lasix 20 mg/day does not indicate an increased risk for HF. The fact that a patient is an African-American man does not indicate an increased risk for HF.
The nurse is caring for a client who was admitted with shortness of breath and has a new diagnosis of heart failure. Which of the following labs indicate that the client is suffering from severe heart failure? LDL 19.2 mmHg BNP 85 pg/mL LDL 192 mg/dL BNP 850 pg/mL
D BNP 850 pg/mL BNP helps quantify the severity of heart failure. A BNP from 600-900 pg/mL indicates severe heart failure. BNP 85 pg/mL This is a normal value for BNP. LDL 192 mg/dL LDL is a measurement of low density lipoproteins. This does not provide any further information about heart failure, but it does give an indication of cholesterol level and overal cardiovascular risk. The normal level for LDL is <100. LDL 19.2 mmHg LDL does not measure heart failure severity.
A student nurse is taking an exam on the cardiovascular system and knows that which of the following symptoms would be the most concerning? Swollen right leg that is red and hot to touch Swollen bilateral legs with +4 pitting edema Swollen left leg with weeping wounds Right leg with a venous stasis ulcer
A Redness and warmth are signs and symptoms of a DVT. The concern with a DVT is that it will break free and cause a pulmonary embolism, stroke or myocardial infarction. Bilateral pitting edema is likely from congestive heart failure (CHF), which is a chronic (not acute) condition and will need to be seen but is not emergent. Weeping wounds on the leg are probably cellulitis and will need antibiotics but are not emergent. A venous stasis ulcer is also a chronic issue and it will not be something that emergent care will improve right away.
A nurse is performing an assessment on a client with heart failure. The nurse checks the client's peripheral pulses in the feet and documents the pulses as 1+. Which best describes this type of pulse? Weak and barely palpable Normal and easily palpable Bounding and strong Absent
A A. Weak and barely palpable During the nursing head-to-toe assessment, peripheral pulses can be checked and then graded according to their intensity. A nurse who feels a peripheral pulse as described as a 1+ would most likely feel a weak and thready, or barely palpable pulse. Absent A 0 indicates an absent pulse. Bounding and strong A 3+ indicates a bounding pulse. Normal and easily palpable A 2+ indicates a normal pulse.
A nurse is caring for a client with heart failure. During the shift assessment the nurse notes that the client has pitting edema, shortness of breath, and which heart sound? Swooshing Clicking Rubbing Gallop
D If a gallop sound (S3) is heard, this indicates blood prematurely rushing into the ventricle. This is often related to volume overload as seen in heart failure, but could also be caused by pulmonary hypertension or coronary artery disease. Swooshing sounds indicate murmurs, which are evidence of valvular disease (stenosis or regurgitation). Clicks are often heard with mitral valve prolapse or aortic stenosis, or can be heard in someone with a prosthetic valve. Rubbing indicates the presence of inflammation in the pericardium, such as in pericarditis.
A patient in heart failure shows a decrease in the glomerular filtration rate. The patient has been taking digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Considering the change in the patient's status, what change in the medication regimen would the nurse anticipate? a. A change from hydrochlorothiazide (HydroDIURIL) to furosemide (Lasix) b. A change from hydrochlorothiazide (HydroDIURIL) to spironolactone (Aldactone) c. A change from hydrochlorothiazide (HydroDIURIL) to mannitol (Osmitrol) d. A change from digoxin (Lanoxin) to verapamil (Calan)
ANS: A The decrease in the GFR indicates the need for a stronger diuretic to help pull volume off the patient.
A 66-year-old client has been in the hospital for care and management of heart failure. There are orders for discharge and the nurse is reviewing discharge instructions with the client. Which of the following information would be included as part of discharge information for this client? The client should not eat more than 2,000 mg of sodium each day The client should restrict fluid intake to less than 4,000 mL per day The client should not have more than 3 alcoholic beverages per day The client should take non-steroidal anti-inflammatory drugs (NSAIDs) for pain control and not acetaminophen
A Excess sodium intake can cause changes in circulatory volume, potentially increasing fluid and contributing to buildup. Many clients with heart failure are restricted in their dietary sodium to 2,000 mg a day, although in some cases, the provider may allow for more or less, depending on the client's condition. While a client with heart failure may drink alcohol, it must be done in moderation. Three alcoholic beverages per day is too much alcohol, and would be considered moderate to heavy drinking. A client with heart failure should be counseled not to drink more than one alcoholic beverage in a day, and to avoid drinking alcohol every day. NSAIDS may worsen heart failure and should be avoided. Heart failure can cause an increase in fluid in the circulatory system. Most heart failure clients are instructed to restrict fluid to 1,000 to 2,000 mL per day.
A patient with 3+ peripheral edema, V/S = P-112, BP-162/100, R-32, T-98.9 and a low GFR is receiving hydrochlorothiazide (HydroDIURIL). The most effective nursing action would be to a. Administer hydrochlorothiazide as ordered. b. Request furosemide (Lasix). c. Request spironolactone (Aldactone). d. Hydrate the patient to improve the GFR.
ANS: B Furosemide can promote fluid loss even when the GFR is low, whereas the thiazide diuretics are not effective with renal dysfunction.
The potassium-sparing diuretic spironolactone (Aldactone) has been demonstrated to prolong survival and improve heart failure (HF) symptoms by a. Its diuretic effects. b. Blocking receptors for aldosterone. c. Reducing venous pressure. d. Reducing afterload.
ANS: B Spironolactone prolongs survival in patients with HF primarily by blocking receptors for aldosterone.
The nurse is reviewing medication for heart failure. The nurse is correct to assume that the front-line therapy for heart failure currently consists of which regimen? a. Loop diuretic, potassium-sparing diuretic, and cardiac glycoside b. Calcium channel blocker, diuretic, and cardiac glycoside c. Diuretic, ACE inhibitor, and beta blocker d. Beta blocker, calcium channel blocker, and diuretic
ANS: C The first-line therapy for heart failure now consists of three drugs: a diuretic, an ACE inhibitor or angiotensin-receptor blocker (ARB), and a beta blocker.
A nurse is reviewing a patient's medications prior to administration. Which drug-to-drug interactions should most concern the nurse in a patient with a history of heart failure and a potassium level of 5.5 mEq/L? a. Furosemide (Lasix) and enalapril (Vasotec) b. Amlodipine (Norvasc) and spironolactone (Aldactone) c. Eplerenone (Inspra) and spironolactone (Aldactone) d. Metoprolol (Lopressor) and furosemide (Lasix)
ANS: C The greatest risk with eplerenone is hyperkalemia, and combining this drug with a potassium-sparing diuretic creates a significant risk of hyperkalemia.
The nurse is caring for a client admitted to the coronary care unit with an MI. During the second night in the CCU, the client develops HF. A pulmonary artery catheter is inserted to monitor the client for left ventricular function because a) It provides information about pulmonary resistance b) It measures myocardial oxygen consumption c) It controls renal blood flow d) It controls afterload
ANSWER: A
The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patient's sensorium and level of consciousness. Why is the assessment of the patient's sensorium and LOC important in patients with heart failure? a) As the volume of blood the heart ejects decreases, the amount of oxygen transported to the brain decreases b) People in heart failure have heightened sensorium c) Every patient's sensorium and LOC are assessed on admission d) It is not necessary
ANSWER: A
Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? a) 5 to 10 minutes b) 30 to 60 minutes c) 2 to 4 hours d) 6 to 8 hours
ANSWER: A Rationale: After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.
A 69-year-old female has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema. On admission of this client, which of the following should the nurse assess first? a) Blood pressure b) Skin breakdown c) Serum potassium level d) Urine output
ANSWER: A Rationale: It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown on admission; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.
The nurse is admitting a 68-year-old male to the medical floor. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? a) Assess respiratory status b) Draw blood for laboratory studies c) Insert a Foley catheter d) Weigh the client
ANSWER: A Rationale: The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate, lung sounds, and Sp02 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.
The nurse is performing a physical assessment on a patient suspected of being in heart failure. What sign that the heart is beginning to fail does the nurse auscultate the chest for? a) An S3 heart sound b) Crackles c) Wheezing d) An S4 heart sound
ANSWER: A Rationale: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. Crackles and wheezing may be heard in a patient with heart failure but do not indicate that the heart is beginning to fail. An S4 heart sound in an adult is pathologic and usually indicates a stiff left ventricle and denotes the beginning of left ventricular failure.
When there is resistance to left ventricular filling, blood backs up into the pulmonary circulation. What does this cause? a) Flash pulmonary edema b) Right-sided heart failure c) Right ventricular hypertrophy d) Left-sided heart failure
ANSWER: A Rationale: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema, sometimes called "flash pulmonary edema," from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided heart failure, left-sided heart failure, and right ventricular hypertrophy do not happen.
Which of the following nursing diagnoses would be appropriate for a client with systolic heart failure? Select all that apply. a) Ineffective peripheral tissue perfusion related to a decreased stroke volume b) Activity intolerance related to impaired gas exchange and perfusion c) Dyspnea related to pulmonary congestion and impaired gas exchange d) Decreased cardiac output related to impaired cardiac filling e) Impaired renal perfusion related to a decreased cardiac output
ANSWER: A, B, C, E Rationale: A decrease in cardiac output occurs from a decreased stroke volume with impaired contractility in systolic heart failure. This impairs peripheral and renal perfusion. The impaired perfusion and impaired oxygenation cause the symptoms of activity intolerance. The decreased systolic function causes an increase in residual volume and pressure in the left ventricle. A retrograde buildup of pressure from the left ventricle to left atria increases hydrostatic pressure in the pulmonary vasculature. This causes a leakage of fluid into the interstitial tissue of the lungs resulting in pulmonary symptoms. With diastolic heart failure, there is impaired ventricular filling due to a rigid ventricle and reduced ventricular relaxation.
When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply. a) Becoming increasingly short of breath at rest b) Weight gain of 2 lbs or more in 1 day c) High intake of sodium for breakfast d) Having to sleep sitting up in a reclining chair e) Weight loss of 2 jobs in 1 day
ANSWER: A, B, D Rationale: The client stating that he would call the physician with increasing shortness of breath, weight gain over 2 lbs in 1 day, and having to sleep sitting up, indicates that he has understood the teaching because these signs and symptoms suggest worsening of the client's heart failure.
You are caring for a patient with HF. You know that the overall goals of management for this patient are what? (Mark all that apply). a) Improve functional status b) Increase cardiac contractility c) Extend survival d) Decrease pulmonary venous pressure e) Relieve patient symptoms
ANSWER: A, C, E Rationale: The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival. The goals of management of the patient with HF do not include increasing cardiac contractility or decreasing pulmonary venous pressure.
A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided heart failure. The patient is agitated and coughing up pink-tinged, foamy sputum. What should the nurse recognize these signs and symptoms of? a) Right-sided heart failure b) Acute pulmonary edema c) Pneumonia d) Cardiogenic shock
ANSWER: B Rationale: Because of decreased contractility and increased fluid volume and pressure in patients with heart failure, fluids may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.
Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse should suspect atrial fibrillation when palpation of the radial pulse reveals: a) Two regular beats followed by one irregular beat b) An irregular pulse rhythm c) Pulse rate below 60 bpm d) A weak, thready pulse
ANSWER: B Rationale: Characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the physician. A weak, thready pulse is characteristic of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction.
The nursing instructor is teaching the beginning nursing class how to assess for hepatojugular reflux. How does the nursing instructor teach the student nurses to assess for hepatojugular reflux? a) Elevate the patient's head to 90 degrees b) Press the right upper abdomen c) Press the left upper abdomen d) Lie the patient flat in bed
ANSWER: B Rationale: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.
You are assessing a patient suspected of having a right-sided HF. What assessment finding may indicate rightsided HF? a) Pulmonary edema b) Distended neck veins c) Dry cough d) Orthopnea
ANSWER: B Rationale: Right-sided heart failure may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness.
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which intervention should be included in the plan? Select all that apply. a) Notify health-care provider of a weight gain of more than one pound in a week b) Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside c) Instruct client to remove the saltshaker from the dinner table d) Encourage client to monitor urine output for change in color or become dark e) Discuss the importance of taking the loop diuretic furosemide at bedtime
ANSWER: B, C Rationale: The client should notify the HCP of weight gain more than 2 or 3 lbs in one day. The client should not take digoxin if radial pulse is less than 60. The client should be on a low sodium diet to prevent water retention. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase with diuretics. Instruct client to take the diuretic in the morning to prevent nocturia.
A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply. a) Angel food cake b) Banana c) Dried fruit d) Orange juice e) Peppers
ANSWER: B, C, D Rationale: Hypokalemia is a side effect of loop diuretics. Bananas, dried fruits, and oranges are examples of food high in potassium. Angel food cake, yellow cake, and peppers are listed by the National Kidney Foundation as low in potassium.
What would be the primary goal of therapy for a client with pulmonary edema and heart failure? a) Enhance comfort b) Increase cardiac output c) Improve respiratory status d) Peripheral edema decreased
ANSWER: C
You are caring for an 84-year-old male who has just returned from the operating room after inguinal hernia repair. You note the patient has fluid volume excess from the OR and is at risk for left-sided HF. What signs and symptoms indicate left-sided HF? a) Jugular vein distention b) Right upper quadrant pain c) Bibasilar fine crackles d) Dependent edema
ANSWER: C Bibasilar fine crackles are a sign of alveolar fluid, a sequel of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
You are caring for a patient with systolic HF who cannot take ACE inhibitors. Which would be the drugs of choice for this patient? a) Loop diuretic b) Angiotensin prohibiters c) Combination of hydralazine and isosorbide dinitrate d) Combination of hydrostatic dinitrate and isosorbide trinitrate
ANSWER: C Rationale: A combination of hydralazine and isosorbide dinitrate may be another alternative for patients who cannot take ACE inhibitors. Loop diuretics are not another alternative for ACE inhibitors. Angiotensin prohibiters and hydrostatic dinitrate with isosorbide trinitrate are distracters for this question.
The nurse should teach the client that signs of digoxin toxicity include which of the following? a) Rash over the chest and back b) Increased appetite c) Visual disturbances such as seeing yellow spots d) Elevated blood pressure
ANSWER: C Rationale: Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with digoxin toxicity.
The nurse's discharge teaching plan for the client with heart failure should stress the importance of which of the following? a) Maintaining a high-fiber diet b) Walking 2 miles every day c) Obtaining daily weights at the same time each day d) Remaining sedentary for most of the day
ANSWER: C Rationale: Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 lbs or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life-threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an exercise program for the client, such as walking 2 miles every day, would not be appropriate at discharge. The client's exercise program would need to be planned in consultation with the physician and based on the history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not prescribe an exercise program for the client, a sedentary lifestyle should not be recommended.
In which of the following positions should the nurse place a client with suspected heart failure? a) Semi-sitting (low Fowler's position) b) Lying on the right side (Sims' position) c) Sitting almost upright (high Fowler's position) d) Lying on the back with the head lowered (Trendelenburg's position)
ANSWER: C Rationale: Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg's position.
Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 am, the nurse reviews the following lab tests. Which of the following should the nurse do first? Lab Results: Sodium 140 mEq/L Potassium 6.8 mEq/L Chloride 101 mEq/L CO2 content 26 mEq/L BUN 18 mg/dL Creatinine 1.0 mg/dL Hemoglobin 12 g/dL Hematocrit 37% a) Administer the medication b) Call the physician c) Withhold the captopril d) Question the metoprolol dose
ANSWER: C Rationale: The nurse should withhold the dose of captopril; captopril is an ACE-inhibitor and a side effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld.
You are doing discharge teaching with a patient diagnosed with HF. What would you teach this patient to do to assess fluid balance? a) Monitor B/P b) Assess radial pulses c) Monitor weight daily d) Monitor bowel movements
ANSWER: C Rationale: To monitor fluid balance at home, 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.
A patient with heart failure cannot take ACE inhibitors because of cough. What drugs can be used as an alternative to ACE inhibitors? a) Calcium channel blockers b) Loop diuretics c) Anti-hypertensives d) Angiotensin II receptor blockers
ANSWER: D
The student nurses are studying the possible complications of HF. What would the nurse mean if he documented on the chart that the patient is experiencing orthopnea? a) Difficulty breathing without use of oxygen b) Difficulty breathing while sitting upright c) Difficulty breathing with movement d) Difficulty breathing when lying flat
ANSWER: D
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a: a) Low sodium level b) High glucose level c) High calcium level d) Low potassium level
ANSWER: D Rationale: A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity.
Which of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility? a) Beta-adrenergic blockers b) Calcium channel blockers c) Diuretics d) Inotropic agents
ANSWER: D Rationale: Inotropic agents are administered to increase the force of the heart's contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-blockers and calcium channel blockers decrease the heart rate and ultimately decrease the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.
Which of the following symptoms is the most likely origin of pain the client described as knifelike chest pain that increases in intensity with inspiration? a) Cardiac b) Gastrointestinal c) Musculoskeletal d) Pulmonary
ANSWER: D Rationale: Pulmonary pain is generally described by these symptoms. Musculoskeletal pain only increases with movement. Cardiac and GI pains don't change with respiration.
The nurse has written an outcome goal "Demonstrates tolerance for increased activity " for a client diagnosed with CHF. Which intervention should the nurse implement to assist the client to achieve this outcome? a) Measure intake and output b) Provide 2g sodium diet c) Weight client daily d) Plan for frequent rest periods
ANSWER: D Rationale: Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome.
Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet? a) Apples b) Tomato juice c) Whole wheat bread d) Beef tenderloin
ANWER: B Rationale: Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.
The nurse knows that the client is experiencing left-sided heart failure based on which of the following assessments? Select all that apply. Cheyne-stokes respirations Dyspnea Pitting leg edema Pulmonary edema Liver enlargement
B, D Dyspnea In heart failure, LEFT backs up to the LUNGS, while RIGHT backs up to the REST of the body. Therefore pulmonary edema and dyspnea would be symptoms of left-sided heart failure. Pulmonary Edema The left side of the heart backs up to the lungs, so pulmonary edema is seen in left-sided heart failure. Cheyne-stokes respirations Although this is pulmonary related, it is not a sign specific to left-sided heart failure. Instead, it may accompany other medical conditions, such as stroke and central sleep apnea. It is also seen in the last hours of life. Pitting leg edema This is seen in right-sided heart failure, as the RIGHT backs up to the REST of the body. Liver enlargement This is seen in right-sided heart failure, as the RIGHT backs up to the REST of the body.
A nurse is caring for a post-operative client with a history of heart failure. The client's weight has increased from the previous day, and the nurse notes distended neck veins. During assessment of the client, the client is severely short of breath and has crackles and wheezing on lung auscultation. Which of the following is a priority action for the nurse? Encourage the client to cough and deep breathe and assist to ambulate Assist the client into supine position and notify the provider Promote incentive spirometry and continue to monitor Administer oxygen and prepare for diuretic administration
D This client is experiencing pulmonary edema, which is a life-threatening event. In pulmonary edema, pressure builds up in the lungs from accumulated blood due to the left ventricle's inability to eject blood into the body. (The LEFT side of the heart backs up into the LUNG, the RIGHT side of the heart backs up into the REST of the body.) The client should immediately be placed in high Fowler's position, given oxygen, and quickly assessed for lung sounds and breathing patterns. The nurse will ensure that an IV is in place, and a rapid-acting diuretic is given such as furosemide. Morphine is also commonly given to reduce preload, lessen anxiety and reduce the work of breathing. As always, the nurse documents everything - the event, actions taken, and the response of the client. Cough and deep breaths is useful when a client has developed atelectasis or accumulation of fluid in the lungs, but not when the fluid is due to pulmonary edema. The cause of the edema MUST be treated or the condition will worsen. Assisting a client to ambulate in this situation would not be helpful, and the client would not be able to tolerate the increased oxygen needs from the work of ambulation. Notifying the provider is an appropriate nursing action in this scenario, but the client must be placed in high Fowler's position. Supine position would make it more difficult for the client to breathe and worsen the condition. Incentive spirometry (IS) is helpful to expand the lungs to prevent or treat atelectasis, or collapsed alveoli. It is not helpful when the source of the lung issues is pulmonary edema. This client is in an emergency situation, and needs diuretic treatment and oxygen therapy. Simply continuing to monitor would be detrimental to this client.
