Chapter 35 Heart Failure Flashcards
While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient’s bed elevated 45 degrees. The nurse knows this finding indicates
a. decreased fluid volume.
b. jugular vein atherosclerosis.
c. increased right atrial pressure.
d. incompetent jugular vein valves.
ANS: C
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 pounds in 24 hours
b. Hourly urine output greater than 60 mL
c. Reduction in patient complaints of chest pain
d. Reduced dyspnea with the head of bed at 30 degrees
ANS: D
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 also may 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 with systolic heart failure and an ejection fraction of 33%?
a. Need to begin an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
d. Importance of making an annual appointment with the primary care provider
ANS: C
The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF)
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops
a. ventricular ectopy.
b. a dry, hacking cough.
c. a systolic BP
ANS: C
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!” The nurse will document this assessment finding as
a. orthopnea.
b. pulsus alternans.
c. paroxysmal nocturnal dyspnea.
d. acute bilateral pleural effusion.
ANS: C
Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.
During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of “feeling too tired to get out of bed.” Based on these data, the best nursing diagnosis for the patient is
a. activity intolerance related to fatigue.
b. disturbed body image related to weight gain.
c. impaired skin integrity related to ankle edema.
d. impaired gas exchange related to dyspnea on exertion.
ANS: A
The patient’s statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems.
The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that
a. she will take furosemide (Lasix) every day at bedtime.
b. the nitroglycerin patch is applied when any chest pain develops.
c. she will call the clinic if her weight goes from 124 to 128 pounds in a week.
d. an additional pillow can help her sleep if she is feeling short of breath at night.
ANS: C
Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an “as needed” basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by further elevating the head of the bed.
When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include
a. canned and frozen fruits.
b. fresh or frozen vegetables.
c. eggs and other high-protein foods.
d. milk, yogurt, and other milk products.
ANS: D
Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include
a. limit dietary sources of potassium.
b. take the hydrochlorothiazide before bedtime.
c. notify the health care provider if nausea develops.
d. skip the digoxin if the pulse is below 60 beats/minute.
ANS: C
Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.
While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the “water pill” with the “heart pill.” When planning for the patient’s discharge the nurse will facilitate a
a. consult with a psychologist.
b. transfer to a long-term care facility.
c. referral to a home health care agency.
d. arrangements for around-the-clock care.
ANS: C
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-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about
a. digitalis preparations.
b. -adrenergic blockers.
c. calcium channel blockers.
d. angiotensin-converting enzyme (ACE) inhibitors.
ANS: D
ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -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-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate?
a. “Because you have diabetes, you would not be a candidate for a heart transplant.”
b. “The choice of a patient for a heart transplant depends on many different factors.”
c. “Your heart failure has not reached the stage in which heart transplants are needed.”
d. “People who have heart transplants are at risk for multiple complications after surgery.”
ANS: B
Indications for a heart transplant include end-stage heart failure (Stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patient’s question.
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
ANS: C
B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A twelve-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.
Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?
a. Monitor blood pressure frequently.
b. Encourage patient to ambulate in room.
c. Titrate nesiritide slowly before stopping.
d. Teach patient about home use of the drug.
ANS: A
Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Because the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in a home setting.
A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective?
a. “I will be sure to take the medication with food.”
b. “I will need to eat more potassium-rich foods in my diet.”
c. “I will call for help when I need to get up to use the bathroom.”
d. “I will expect to feel more short of breath for the next few days.”
ANS: C
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.
