NRS 230 Test #3
What are the major types of heart failure?
- Left-sided heart failure - Right-sided heart failure - High-output failure
What are the characteristics of aortic insufficiency?
-A high-pitched, blowing decrescendo diastolic murmur -The patient may experience palpitations while lying on the left side
What are characteristics of endocarditis?
-A new, regurgitant murmur -Janeway's lesions -Osler's nodes -Petechiae
What is diastolic heart failure?
-Also known as heart failure with preserved left ventricular function -Occurs when the left ventricle cannot relax adequately during diastole
What are the characteristics of aortic stenosis?
-Classic signs of dyspnea, angina, and syncope -Becoming a disorder of aging populations -Murmur, systolic crescendo - decrescendo
Where and why do you hear crackles?
-Crackles are produced by intra-alveolar fluid -Often noted first in the bases of the lungs and spread upward as the condition worsens
What are characteristics of pericarditis?
-Grating pain that is aggravated by breathing -Scratchy, high pitch sound heard on auscultation over left lower sternal border
What are characteristics of mitral valve stenosis?
-Hepatomegaly is a late sign -Irregular rhythm; atrial fibrillation can cause emboli -Right-sided heart failure; later cardiac output fails -Rumbling apical diastolic murmur
What are common causes and risk factors for heart failure?
-Hypertension -Coronary artery disease -Cardiomyopathy -Substance abuse -Valvular disease -Congenital defects -Cardiac infections and inflammations -Dysrhythmias -Diabetes Mellitus -Smoking/tobacco use -Family history -Obesity -Severe lung disease -Sleep apnea -Hyperkinetic conditions
What can cause left-sided (ventricular) heart failure?
-Hypertension -Coronary artery disease -Valvular disease involving the mitral or aortic valve
What can cause high-output heart failure?
-Increased metabolic needs -Hyperkinetic conditions (septicemia, high fever, anemia, and hyperthyroidism)
What is the initial compensatory mechanism of the heart?
-Increased sympathetic stimulation
What dysrhythmias are commonly seen in heart failure?
-Irregular heart rhythm resulting from premature atrial contractions (PACs) -Premature ventricular contractions (PVCs) -Atrial fibrillation (AF)
What can cause right-sided heart (ventricular) failure?
-Left ventricular failure -Right ventricular myocardial infarction (MI) -Pulmonary hypertension
What does the patient with heart failure need to know about diet?
-Limit daily sodium to 2-3 grams a day -Limit daily intake to 2 L
What are five major self-management categories for a patient with heart failure?
-Medications -Activity -Weight -Diet -Symptoms
What are the characteristics of mitral valve prolapse?
-Most patients are asymptomatic -Leaflets enlarge and falls back into left atrium during systole -Normal heart rate and blood pressure
What does the patient with heart failure need to know about symptoms?
-Notify healthcare provider immediately of any new or worsening symptoms
What does the patient with heart failure need to know about weight?
-Obtain daily weight at the same time each day wearing the same clothes -Monitor for fluid retention
What serum electrolytes do you need to regularly evaluate?
-Sodium -Potassium -Magnesium -Calcium -Chloride
What does the patient with heart failure need to know about activity?
-Stay active but avoid overexertion -Know your limits -Make it a goal to be able to talk during exercise
What are the characteristics of rheumatic carditis?
-Streptococcal infection -Aschoff bodies
What happens when the sympathetic nervous system is stimulated?
-Stroke volume (SV) is improved -Results in arterial vasoconstriction (can maintain blood pressure and improve tissue perfusion in low - output states)
What compensatory mechanisms are used when cardiac output is insufficient to meet the demands of the body?
-Sympathetic nervous system stimulation -Renin - angiotensin system (RAS) activation -Other chemical responses -Myocardial hypertrophy
What are manifestations of diastolic heart failure?
-Symptoms of inadequate tissue perfusion -Pulmonary and systemic congestion
What are manifestations of systolic dysfunction?
-Symptoms of inadequate tissue perfusion -Pulmonary and systemic congestion
What does the patient need to know about medications for heart failure?
-Take as prescribed -Prescriptions filled -Know purpose and side effects of each drug
What happens when myocardial hypertrophy occurs?
-The walls of the heart thicken to provide more muscle mass (resulting in more forceful contractions, increasing further cardiac output) -Often a hypertrophy heart is slightly oxygen deprived
What are characteristics of mitral valve insufficiency?
-Usually coexists with some degree of mitral stenosis -Irregular rhythm; atrial fibrillation can cause emboli -Symptoms - free for decades, later related to left ventricle failure -Right - sided failure results in neck vein distention -S3 often present due to severe regurgitation
What happens when the renin - angiotensin system is activated?
-Vasoconstriction becomes more pronounced in response to angiotensin II -Aldosterone secretion causes sodium and water retention -Preload and afterload increase -Angiotensin II contributes to ventricular remodeling
What is B-type natriuretic peptide (BNP)?
A hormone that is produced and released by the ventricles when the patient has fluid overload as a result of heart failure.
The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching? A. "I should avoid eating hamburgers." B. "I must cut out bacon and canned foods." C. "I shouldn't put the salt shaker on the table anymore." D. "I should avoid lunchmeats but may cook my own turkey."
A. "I should avoid eating hamburgers." Cutting out beef or hamburgers made at home is not necessary; however, fast-food hamburgers are to be avoided owing to higher sodium content. Bacon, canned foods, lunchmeats, and processed foods are high in sodium, which promotes fluid retention; these are to be avoided. The client correctly understands that adding salt to food should be avoided.
The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching? A. "I will call the provider if I have a cough lasting 3 or more days." B. "I will report to the provider weight loss of 2 to 3 pounds in a day." C. "I will try walking for 1 hour each day." D. "I should expect occasional chest pain."
A. "I will call the provider if I have a cough lasting 3 or more days." Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified. The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.
At a clinic visit, the nurse provides dietary teaching for a 56-year-old woman who was 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.
A 70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed for her to continue at home. Which response by the nurse is accurate? 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 heart failure 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 about these four clients, which client should the nurse assess first? A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions B. A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% C. A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths D. A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min
A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions The 46-year-old's premature ventricular contractions may be indicative of digoxin toxicity; further assessment for clinical manifestations of digoxin toxicity should be done and the health care provider notified about the dysrhythmia. The 55-year-old is stable and can be assessed after the client with aortic stenosis. The 68-year-old may be assessed after the client with aortic stenosis; this type of pain is expected in pericarditis. Tachycardia is expected in the 79-year-old because rejection will cause signs of decreased cardiac output, including tachycardia; this client may be seen after the client with aortic stenosis.
A patient admitted with heart failure appears very anxious and complains of 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. Administer ordered morphine sulfate. B. Position patient in a semi-Fowler's position. D. Instruct patient on the use of relaxation techniques. E. Use a calm, reassuring approach while talking to patient. 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.
The nurse is caring for a client with heart failure. For which symptoms does the nurse assess? (Select all that apply.) A. Chest discomfort or pain B. Tachycardia C. Expectorating thick, yellow sputum D. Sleeping on back without a pillow E. Fatigue
A. Chest discomfort or pain B. Tachycardia E. Fatigue Decreased tissue perfusion with heart failure may cause chest pain or angina. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Fatigue is a symptom of poor tissue perfusion in clients with heart failure. Presence of a cough or dyspnea results as pulmonary venous congestion ensues. Clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. Thick, yellow sputum is indicative of infection. Position for sleeping isn't a symptom; Clients usually find it difficult to lie flat because of dyspnea symptoms.
The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client's HF? A. Ibuprofen (Motrin) B. Hydrochlorothiazide (HydroDIURIL) C. NPH insulin D. Levothyroxine (Synthroid)
A. Ibuprofen (Motrin) Long-term use of nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) causes fluid and sodium retention, which can worsen a client's HF. A diuretic may be used in the treatment of HF and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause HF. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism; it does not cause HF.
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 (ACE) inhibitor at discharge E. Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen
A. Left ventricle function is documented D. Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge E. Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen The Joint Commission has identified these three 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.
A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? A. Reduce preload. B. Decrease afterload. C. Increase contractility. D. Promote vasodilation.
A. Reduce preload. Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.
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 ADHF? A. Take medications as prescribed. B. Use oxygen when feeling short of breath. C. Only ask the physician's office questions. 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.
What is an S3 gallop?
An early diastolic filling sound indicating an increase in left ventricular pressure.
The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? A. Assess the client for peripheral edema. B. Auscultate the client's posterior breath sounds. C. Notify the health care provider about the client's weight gain. D. Remind the client about dietary sodium restrictions.
B. Auscultate the client's posterior breath sounds. Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds. Assessment of edema may be delayed until after breath sounds are assessed. After a full assessment, the nurse should notify the health care provider. After physiologic stability is attained, then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.
Which medication, when given in heart failure, may improve morbidity and mortality? A. Dobutamine (Dobutrex) B. Carvedilol (Coreg) C. Digoxin (Lanoxin) D. Bumetanide (Bumex)
B. Carvedilol (Coreg) Beta-adrenergic blocking agents such as carvedilol reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; this category of pharmacologic agents improves morbidity, mortality, and quality of life. Dobutamine and digoxin are inotropic agents used to improve myocardial contractility but have not been directly associated with improving morbidity and mortality. Bumetanide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.
How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? A. Ejection fraction is 25%. B. Client states that she is able to sleep on one pillow. C. Client was hospitalized five times last year with pulmonary edema. D. Client reports that she experiences palpitations.
B. Client states that she is able to sleep on one pillow. Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. An ejection fraction of 25% is well below the normal of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.
Which client is best to assign to an LPN/LVN working on the telemetry unit? A. Client with heart failure who is receiving dobutamine (Dobutrex) B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea C Client with pericarditis who has a paradoxical pulse and distended jugular veins D. Client with rheumatic fever who has a new systolic murmur
B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea The client with dilated cardiomyopathy who needs oxygen only with exertion is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. The client with heart failure is receiving an intravenous inotropic agent, which requires monitoring by the RN. The client with pericarditis is displaying signs of cardiac tamponade and requires immediate lifesaving intervention. The client with a new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the RN.
A client who has been admitted for the third time this year for heart failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? A. Calls the family to lift the client's spirits B. Considers further assessment for depression C. Sedates the client to decrease myocardial oxygen demand D. Tells the client that things will get better
B. Considers further assessment for depression This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done. Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope, and ignores the client's feelings.
A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. What should this patient be taught to avoid? A. High-potassium foods B. Drugs to treat erectile dysfunction C. Nonsteroidal antiinflammatory drugs D. Over-the-counter H2-receptor blockers
B. Drugs to treat erectile dysfunction The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. High-potassium foods, NSAIDs, and H2-receptor blockers do not pose a risk in combination with nitrates.
What should the nurse recognize as an indication for the use of dopamine (Intropin) 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.
A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription? A. Serum sodium level of 135 mEq/L B. Serum potassium level of 2.8 mEq/L C. Serum creatinine of 1.0 mg/dL D. Serum magnesium level of 1.9 mEq/L
B. Serum potassium level of 2.8 mEq/L Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy. A serum sodium level of 135 mEq/L is a normal value. Heart failure may cause renal insufficiency, but a serum creatinine of 1.0 mg/dL represents a normal value. A diuretic may deplete magnesium, but a serum magnesium level of 1.9 mEq/L represents a normal value.
The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, 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 100.4o F and pulse is 102 beats/minute Respirations 26 breaths/minute despite oxygen by nasal cannula
B. Severe dyspnea and blood-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths per minute, 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.
The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? (Select all that apply.) A. Hypokalemia B. Sinus bradycardia C. Fatigue Correct D. Serum digoxin level of 1.5 E. Anorexia
B. Sinus bradycardia E. Anorexia Digoxin toxicity may cause bradycardia. Fatigue and anorexia are symptoms of digoxin toxicity. Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. A serum digoxin level between 0.8 and 2.0 is considered normal and is not a symptom.
A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication? A. The client's ability to understand medication teaching B. The risk for hypotension C. The potential for bradycardia D. Liver function tests
B. The risk for hypotension Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, understanding of teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.
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 should the nurse do next? 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 report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.
The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? A. "How does this make you feel?" B. "This can be caused by taking performance-enhancing drugs." C. "This may be caused by a genetic trait." D. "Just imagine how bad it would be if you weren't in good shape."
C. "This may be caused by a genetic trait." Hypertrophic cardiomyopathy is often transmitted as a single gene autosomal dominant trait. Exploring the client's feelings is important, but does not address the client's question. Hypertrophic cardiomyopathy is not caused by performance-enhancing drugs. Reminding the client that he or she is in good shape is not at all therapeutic and does not address the client's question.
A 54-year-old male 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. Perform a bladder scan to assess for urinary retention. B. Restrict the patient's oral fluid intake to 500 mL per day. C. Assist the patient to a sitting position with arms on the overbed table. D. Instruct 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.
Which diagnostic test result is consistent with a diagnosis of heart failure (HF)? A. Serum potassium level of 3.2 mEq/L B. Ejection fraction of 60% C. B-type natriuretic peptide (BNP) of 760 ng/dL D. Chest x-ray report showing right middle lobe consolidation
C. B-type natriuretic peptide (BNP) of 760 ng/dL BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia may occur in response to diuretic therapy for HF, but may also occur with other conditions; it is not specific to HF. Ejection fraction of 60% represents a normal value of 50% to 70%. Consolidation on chest x-ray may indicate pneumonia.
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.
The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea; pink, frothy sputum; and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Physical Assessment Findings: Crackles in all fields S3 present Oliguria Diagnostic Findings: Ejection fraction 30% BNP 560 Sodium 130 mEq/L Provider Prescriptions: Enalapril 10 mg orally daily Heparin 5000 units subcutaneously every 12 hours Furosemide 40 mg IV daily Diagnosis: heart failure Strict I & O Which prescription does the nurse implement first? A. Enalapril B. Heparin C. Furosemide D. Intake and output (I & O)
C. Furosemide The client is displaying typical signs of acute pulmonary edema secondary to fluid-filled alveoli and pulmonary congestion; a diuretic will promote fluid loss. Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis secondary to immobility, but will not reduce fluid excess. Although all clients with congestive heart failure should have daily weights and I & O monitored, this is not a priority; removing fluid volume and treating dyspnea are matters of priority.
Which nursing action may be delegated to a nursing assistant working on the medical unit? A. Determine the usual alcohol intake for a client with cardiomyopathy. B. Monitor the pain level for a client with acute pericarditis. C. Obtain daily weights for several clients with class IV heart failure. D. Check for peripheral edema in a client with endocarditis.
C. Obtain daily weights for several clients with class IV heart failure. Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments; determining alcohol intake, monitoring pain level, and assessing for peripheral edema should not be delegated.
Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea? A. Monitor pulse oximetry and cardiac rate and rhythm. B. Reassure the client that his distress can be relieved with proper intervention. C. Place the client in high-Fowler's position with the legs down. D. Ask a family member to remain with the client.
C. Place the client in high-Fowler's position with the legs down. High-Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member's presence may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.
The nurse prepares to administer digoxin (Lanoxin) 0.125 mg to an 82-year-old man 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.
The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? A. Friction rub auscultated at the left lower sternal border B. Pain aggravated by breathing, coughing, and swallowing C. Splinter hemorrhages D. Thickening of the endocardium
C. Splinter hemorrhages Splinter hemorrhages are indicative of infective endocarditis. Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.
Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? A. The client ambulates around the nursing unit with a walker. B. The nurse monitors the client's pulse and blood pressure frequently. C. The nurse obtains a bedside commode before administering furosemide. D. The nurse returns the client to bed when he becomes tachycardic.
C. The nurse obtains a bedside commode before administering furosemide. Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.
When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? A. Auscultation of crackles B. Pedal edema C. Weight loss of 6 pounds since the last visit D. Reports sucking on ice chips all day for dry mouth
C. Weight loss of 6 pounds since the last visit Weight loss in this client indicates effective fluid restriction and diuretic drug therapy. Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. Sucking on ice chips indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.
The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? A. Muscle aches B. Constipation C. Pounding headache D. Anorexia and nausea
D. Anorexia and nausea Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac 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 stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning 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.
Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? A. Infection B. Acute rejection C. Immunosuppression D. Cardiac vasculopathy
D. Cardiac vasculopathy Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) 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 male patient with a long-standing history of heart failure has 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 commonly used in the care of hospice patients.
The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8° F Pulse: 48 beats/min and irregular Respirations: 20 breaths/min Potassium level: 3.2 mEq/L What action does the nurse take? A. Give the digoxin; reassess the heart rate in 30 minutes. B. Give the digoxin; document assessment findings in the medical record. C. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. D. Hold the digoxin, and obtain a prescription for a potassium supplement.
D. Hold the digoxin, and obtain a prescription for a potassium supplement. Digoxin causes bradycardia; hypokalemia potentiates digoxin. Because digoxin causes bradycardia, the medication should be held. Furosemide decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid volume excess at this time.
The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? A. Determines the client's physical limitations B. Encourages alternate rest and activity periods C. Monitors and documents heart rate, rhythm, and pulses D. Positions the client to alleviate dyspnea
D. Positions the client to alleviate dyspnea Positioning the client to alleviate dyspnea will help ease air hunger and anxiety. Administering oxygen therapy is also an important priority action. Determining the client's physical limitations is not a priority in this situation. Encouraging alternate rest and activity periods is not the immediate priority. Monitoring of heart rate, rhythm, and pulses is important, but is not the priority.
After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? A. ADHF B. Chronic HF C. Left-sided HF D. Right-sided HF
D. 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.
A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective? A. The client has diuresis of 400 mL in 24 hours. B. The client's blood pressure is 122/84 mm Hg. C. The client has an apical pulse of 82 beats/min. D. The client's weight decreases by 2.5 kg.
D. The client's weight decreases by 2.5 kg. The best indicator of fluid volume gain or loss is daily weight; because each kilogram represents approximately 1 liter, this client has lost approximately 2500 mL of fluid. Diuresis of 400 mL in 24 hours represents oliguria. Although a blood pressure of 122/84 mm Hg is a normal finding, alone it is not significant for relief of hypervolemia. Although an apical pulse of 82 beats/min is a normal finding, alone it is not significant to determine whether hypervolemia is relieved.
What are key features of left-sided heart failure?
Decreased cardiac output: -Fatigue -Weakness -Oliguria during the day and nocturia at night -Angina -Confusion, restlessness -Dizziness -Tachycardia, palpitations -Pallor -Weak peripheral pulses -Cool extremities Pulmonary congestion: -Hacking cough, worse at night -Dyspnea, breathlessness -Crackles or wheezes in lungs -Frothy, pink-tinged sputum -Tachypnea -S3/S4 summation gallop
What is cardiac tamponade?
Excess fluid in the pericardial cavity
What is pulsus paraxodus?
Having a systolic blood pressure higher on expiration than on inspiration
Where does most heart failure begin?
Most heart failure begins with the failure of the left ventricle and progresses to failure of both ventricles.
What is the ACC/AHA staging system compared with the NYHA system?
Patient is at high risk for developing heart failure (class I NYHA) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (class I NYHA) Patients with current or prior symptoms of heart failure (class I or II NYHA) Patients with refractory end-stage heart failure (class IV NYHA)
What is petechiae?
Red, flat pinpoint spots/lesions in mucous membrane and conjunctivae
What is pericardial friction rub?
Scratchy, high-pitched sound heard at the left lower sternal border
What are Aschoff bodies?
Small nodules on myocardium replaced by scar tissue
What are splinter hemorrhages?
Small red streaks or black longitudinal lines of nail beds
What are the key features of right sided heart failure?
Systemic congestion: -Jugular distention -Enlarged liver and spleen -Anorexia and nausea -Dependent edema (legs and sacrum) -Distended abdomen -Swollen hands and fingers -Polyurea at night -Weight gain -Increased blood pressure (from excess volume) or decreased blood pressure (from failure)
What causes most cases of heart failure?
Systemic hypertension
What happens to the ejection fraction during systolic heart failure?
The ejection fraction (the percentage of blood ejected from the heart during systole) drops from a normal of 50%-70% to below 40% with ventricular dilation.
What is heart failure?
The inability of the heart to work effectively as a pump.
What is systemic emboli?
Vegetation fragments in circulation resulting in a cerebrovascular accident (CVA) or transient ischemic attack (TIA)
When are patients are considered candidates for an implantable cardioverter/defibrillator (ICD)?
When the ejection fraction is 30% or less.
What is systolic heart failure (systolic ventricular dysfunction)?
When the heart cannot contract forcefully enough during systole to eject adequate amounts of blood into the circulation.
