Chapter 34 : Heart Failure Flashcards
While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient’s bed elevated 45 degrees. What does this finding indicate?
a. Decreased fluid volume.
b. Jugular vein atherosclerosis.
c. Increased right atrial pressure.
d. Incompetent jugular vein valves.
Answer: 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. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?
a. Weight loss of 2 lb in 24 hours.
b. Hourly urine output greater than 60 mL.
c. Reduced dyspnea with the head of bed at 30 degrees.
d. Patient denies experiencing chest pain or chest pressure.
Answer: c. Reduced dyspnea with the head of bed at 30 degrees.
Rationale: Because the patient’s major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data may also indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient’s response.
Which topic will the nurse plan to include in discharge teaching for a patient who has heart failure with reduced ejection fraction (HFrEF)?
a. Need to begin an aerobic exercise program several times weekly.
b. Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors.
c. Use of salt substitutes to replace table salt when cooking and at the table.
d. Importance of making an annual appointment with the health care provider.
Answer: b. Benefits and 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 below 40% should receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure. Salt substitutes are not usually recommended because of the risk of hyperkalemia. The patient will need to see the primary care provider more often than annually.
IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. Which reassessment finding during the first hours of administration indicates that the nurse should decrease the rate of nitroprusside infusion?
a. Ventricular ectopy.
b. Dry, hacking cough.
c. Systolic BP below 90 mm Hg.
d. Heart rate below 50 beats/min.
Answer: c. Systolic BP below 90 mm Hg.
Rationale: Sodium nitroprusside is a potent vasodilator and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.
A patient 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!” How should the nurse document this finding?
a. Orthopnea.
b. Pulsus alternans.
c. Paroxysmal nocturnal dyspnea.
d. Acute bilateral pleural effusion.
Answer: 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. Pulsus alternans is the alteration of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.
Which statement by a patient with newly diagnosed heart failure indicates to the nurse that teaching was effective?
a. “I will take furosemide (Lasix) every day just before bedtime.”
b. “I will use the nitroglycerin patch whenever I have chest pain.”
c. “I will use an additional pillow if I am short of breath at night.”
d. “I will call the clinic if my weight goes up 3 pounds in a week.”
Answer: d. “I will call the clinic if my weight goes up 3 pounds in a week.”
Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 lb in 2 days or 3 to 5 lb in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an “as needed” basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops rather than just compensating by further elevating the head of the bed.
When teaching a patient with heart failure on a 2000-mg sodium diet, which foods should the nurse recommend limiting?
a. Chicken and eggs.
b. Canned and frozen fruits.
c. Yogurt and milk products.
d. Fresh or frozen vegetables.
Answer: c. Yogurt and milk products.
Rationale: Yogurt and milk products (e.g., cheese) naturally contain a significant amount of sodium, and the intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. The other foods listed have minimal levels of sodium and can be eaten without restriction
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Which instruction should the nurse include?
a. Limit dietary sources of potassium.
b. Take the hydrochlorothiazide at bedtime.
c. Notify the health care provider if nausea develops.
d. Take the digoxin if the pulse is below 60 beats/min.
Answer: c. Notify the health care provider if nausea develops.
Rationale: Nausea is a symptom of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60 beats/min, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.
While admitting an 82-yr-old patient 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.” What should the nurse include in the discharge plan?
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.
Answer: 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. A home health nurse will assess the patient’s home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care.
Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. What medication topic should the nurse anticipate including in discharge teaching?
a. Beta-Adrenergic blockers.
b. Calcium channel blockers.
c. Digitalis and potassium therapy regimen.
d. Angiotensin-converting enzyme (ACE) inhibitors.
Answer: 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 myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other drugs such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The -adrenergic blockers are not used as initial therapy for new onset heart failure.
A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is an option. Which response is accurate?
a. “Your heart failure has not reached the end stage yet.”
b. “You could not manage the multiple complications of that surgery.”
c. “The suitability of a heart transplant for you depends on many factors.”
d. “Because you have diabetes, you would not be a heart transplant candidate.”
Answer: c. “The suitability of a heart transplant for you depends on many 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. Patients with diabetes who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, there are no data to suggest that the patient could not manage the care.
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.
Answer: c. B-type natriuretic peptide.
Rationale: B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A 12-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.
Which action should the nurse include in the plan of care 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. Teach patient to drink at least 3 liters of fluid daily.
d. Titrate nesiritide dose down slowly before stopping.
Answer: a. Monitor blood pressure frequently.
Rationale: Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Because the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration. Excessive hydration could exacerbate ADHF.
A patient with chronic heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective?
a. “I plan to take the medication with food.”
b. “I should eat more potassium-rich foods.”
c. “I will call for help when I need to get up to use the bathroom.”
d. “I can expect to feel more short of breath for the next few days.”
Answer: 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. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of -adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.
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. captopril (Capoten) 25 mg.
b. furosemide (Lasix) 60 mg.
c. digoxin (Lanoxin) 0.125 mg.
d. carvedilol (Coreg) 3.125 mg.
Answer: d. carvedilol (Coreg) 3.125 mg
Rationale: Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other drugs are appropriate for the patient with ADHF.
