Midterm Flashcards
Which patient statement indicates that the nurse‘s teaching about carvedilol (Coreg) for preventing anginal episodes has been effective?
a. “Carvedilol will help my heart muscle work harder.”
b. “It is important not to suddenly stop taking the carvedilol.”
c. “I can expect to feel short of breath when taking carvedilol.”
d. “Carvedilol will increase the blood flow to my heart muscle.”
b. “It is important not to suddenly stop taking the carvedilol.”
Rationale: Patients who have been taking b-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking b-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O 2 demand, not by increasing blood flow to the coronary arteries.
Diltiazem is prescribed for a patient newly diagnosed with Prinzmetal‘s (variant) angina.
Which action of diltiazem is accurate for the nurse to include in the teaching plan?
a. Reduces heart palpitations.
b. Prevents coronary artery plaque.
c. Decreases coronary artery spasms.
d. Increases contractile force of the heart.
c. Decreases coronary artery spasms.
Rationale: Prinzmetal‘s angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and b-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand.
Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. Which data would indicate to the nurse that the drug is effective?
a. Decreased blood pressure and heart rate
b. Improvement in the strength of the distal pulses
c. Fewer complaints of having cold hands and feet
d. Participation in daily activities without chest pain
d. Participation in daily activities without chest pain
Rationale: Because the drug is ordered to improve the patient‘s angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective b-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.
A patient with diabetes mellitus and chronic stable angina has a new order for captopril.
Which information would the nurse teach this patient about the primary purpose of captopril?
a. Decreases the heart rate.
b. Controls blood glucose levels.
c. Prevents changes in heart muscle.
d. Reduces the frequency of chest pain.
c. Prevents changes in heart muscle.
Rationale: The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.
A patient who has recently started taking pravastatin (Pravachol) and niacin reports several new symptoms to the nurse. Which information is most important to communicate to the health care provider?
a. Generalized muscle aches and pains
b. Dizziness with rapid position changes
c. Nausea when taking the drugs before meals
d. Flushing and pruritus after taking the drugs
a. Generalized muscle aches and pains
Rationale: Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.
A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient‘s care?
a. Sildenafil (Viagra)
b. Furosemide (Lasix)
c. Warfarin (Coumadin)
d. Diltiazem (Cardizem)
a. Sildenafil (Viagra)
Rationale: The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient‘s treatment.
A patient who has chest pain is admitted to the emergency department (ED), and all of the following items are prescribed. Which one would the nurse arrange to be completed first?
a. Chest x-ray
b. Troponin level
c. Electrocardiogram (ECG)
d. Insertion of a peripheral IV
c. Electrocardiogram (ECG)
Rationale: The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that the appropriate therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient‘s care but are not helpful in determining whether the patient is experiencing a myocardial infarction. Peripheral IV access will be needed but not before the ECG.
After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient would the nurse assess first?
a. A 39-year-old patient with pericarditis who is complaining of sharp, stabbing chest pain
b. A 56-year-old patient with variant angina who is scheduled to receive nifedipine (Procardia)
c. A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today‘s planned discharge
d. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)
d. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)
Rationale: After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient‘s blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.
Which patient at the cardiovascular clinic requires the most immediate action by the nurse?
a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL
b. Patient with stable angina whose chest pain has recently increased in frequency
c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL
d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg
b. Patient with stable angina whose chest pain has recently increased in frequency
Rationale: The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are more stable.
The nurse is caring for a patient who is receiving IV furosemide 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
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 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
b. Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors
Rationale: Patients with HFrEF would receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be possible 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.
A patient who has chronic heart failure tells the nurse, “I was fine when I went to bed, but I woke up feeling like I was suffocating!” How would the nurse document this finding?
a. Orthopnea
b. Pulsus alternans
c. Paroxysmal nocturnal dyspnea
d. Acute bilateral pleural effusion
c. Paroxysmal nocturnal dyspnea
Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. 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 newly diagnosed with 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.”
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.
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 would 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
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. Which medication topic would the nurse anticipate including in discharge teaching?
a. Calcium channel blocker
b. Selective SA node inhibitor
c. Digoxin and potassium therapy regimen
d. Angiotensin-converting enzyme (ACE) inhibitor
d. Angiotensin-converting enzyme (ACE) inhibitor
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. Ivabradine would likely be used for a patient with HF who has symptoms despite optimal doses of other medications.
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 surgery.”
c. “The suitability of a heart transplant depends on many factors.”
d. “Because you have diabetes, you would not be a heart transplant candidate.”
c. “The suitability of a heart transplant 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
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 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.
A hospitalized 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.”
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 chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?
a. Auscultate the abdomen.
b. Check the capillary refill.
c. Auscultate the breath sounds.
d. Ask about the patient‘s allergies.
c. Auscultate the breath sounds.
Rationale: This patient‘s severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) may be occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient‘s volume status and should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor is on a low-sodium diet. The patient tells the home health nurse about a 5-lb weight gain in the past 3 days. Which action is the nurse‘s priority?
a. Teach the patient about restricting dietary sodium.
b. Assess the patient for manifestations of acute heart failure.
c. Ask the patient about the use of the prescribed medications.
d. Have the patient recall the dietary intake for the past 3 days.
b. Assess the patient for manifestations of acute heart failure.
Rationale: The 5-lb weight gain over 3 days indicates that the patient‘s chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.
A patient in the intensive care unit who has acute decompensated heart failure (ADHF) reports severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been prescribed for the patient. Which action would the nurse take first?
a. Give PRN IV morphine sulfate 4 mg.
b. Give PRN IV diazepam (Valium) 2.5 mg.
c. Increase nitroglycerin infusion by 5 mcg/min.
d. Increase dopamine infusion by 2 mcg/kg/min.
a. Give PRN IV morphine sulfate 4 mg.
Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires immediate action by the nurse?
a. O2 saturation of 88%
b. Weight gain of 1 kg (2.2 lb)
c. Heart rate of 106 beats/min
d. Urine output of 50 mL over 2 hours
a. O2 saturation of 88%
Rationale: A decrease in O2 saturation to less than 92% indicates hypoxemia, and the nurse would start supplemental O2 immediately. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output may also indicate worsening heart failure and require nursing actions, but the low O 2 saturation rate requires the most immediate nursing action.
A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?
a. Presence of 1+ to 2+ edema in the feet and ankles
b. Palpable liver edge 2 cm below the ribs on the right side
c. Serum potassium level 3.0 mEq/L after 1 week of therapy
d. Weight increase from 120 pounds to 122 pounds over 3 days
c. Serum potassium level 3.0 mEq/L after 1 week of therapy
Rationale: Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions) and potentiate the actions of digoxin. Hypokalemia also increases the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patient‘s heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.
An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider?
a. 2+ bilateral pedal edema
b. Heart rate of 52 beats/min
c. Report of increased fatigue
d. Blood pressure 88/42 mm Hg
d. Blood pressure 88/42 mm Hg
Rationale: The patient‘s blood pressure indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of -adrenergic blockade, though it may need to be monitored. -Adrenergic blockade initially will worsen symptoms of heart failure in many patients and patients would be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.
The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action would the nurse include in the plan of care?
a. Avoid the use of anticoagulant medications.
b. Monitor the patient‘s urinary output every hour.
c. Provide passive range of motion for all extremities.
d. Position the patient supine with head flat at all times.
b. Monitor the patient‘s urinary output every hour.
Rationale: Monitoring urine output will help determine whether the patient‘s cardiac output has improved. It also will help assess for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.
