Unit6: Chapter 44 (Karch 7th Ed) - Agents for Treating Heart Failure

Question 1

1. A patient presents to the emergency department with rales, wheezing, and blood-tinged sputum. What
   does the nurse recognize that these symptoms indicate?
   A) Cardiomyopathy
   B) Cardiomegaly
   C) Valvular heart disease
   D) Pulmonary edema

Answer 1

Ans: D
Feedback:
In left-sided heart failure, the left ventricle pumps inefficiently resulting in a backup of blood into the
lungs causing pulmonary vessel congestion and fluid leaks into the alveoli and lung tissue. As more
fluid continues to collect in the alveoli, pulmonary edema develops. The patient will present with rales,
wheezes, blood-tinged sputum, low oxygenation, and development of a third heart sound.
Cardiomyopathy can occur as a result of a viral infection, alcoholism, anabolic steroid abuse, or a
collagen disorder. It causes muscle alterations and ineffective contraction and pumping. Cardiomegaly
is an enlargement of the heart due to compensatory mechanisms in congestive heart failure (CHF) and
leads to ineffective pumping and eventually exacerbated CHF. Valvular heart disease leads to an
overload of the ventricles because the valves do not close adequately causing blood to leak backward.
This causes muscle stretching and increased demand for oxygen and energy.

Question 2

2. What electrolyte inactivates troponin and allows actin and myosin to form a bridge enabling the muscle
fibers to contract?
A) Magnesium
B) Calcium
C) Potassium
D) Sodium

Answer 2

Ans: B
Feedback:
Calcium must be present to deactivate troponin so that actin and myosin can react to form actinomycin bridges. Potassium, sodium, and magnesium do not affect troponin.

Question 3

3. A 62-year-old African American man diagnosed with congestive heart failure and hypertension has
   BiDil included in his drug therapy. What nursing assessment finding would indicate the patient is
   developing a complication from this drug?
   A) Alopecia
   B) Photosensitivity
   C) Anorexia
   D) Orthostatic hypotension

Answer 3

Ans: D
Feedback:
Orthostatic hypotension is an adverse effect of a combination of isosorbide dinitrate and hydralazine
called BiDil. This could lead to safety concerns and should be addressed in drug teaching for this
patient. Alopecia, photosensitivity, and anorexia are not adverse effects related to this drug.

Question 4

4. The nurse is preparing digoxin for an infant. What is the nurse’s priority intervention?
   A) To perform hand hygiene
   B) To have another nurse check dosage calculations
   C) To check the child’s apical pulse
   D) To identify the patient by checking the ID bracelet

Answer 4

Ans: B
Feedback:
The margin of safety for the dosage of this drug is very narrow in children. The dosage needs to be very
carefully calculated and should be double-checked by another nurse before administration. The other
options are important and the nurse should implement all three. However, these actions are of lower
priority.

Question 5

5. A patient asks the nurse what cardiac glycosides do to improve his condition. What is the nurse’s best
   response?
   A) They decrease the force of myocardial contractions.
   B) They help renal blood flow and increase urine output.
   C) They increase heart rate.
   D) They increase conduction velocity

Answer 5

Ans: B
Feedback:
Cardiac glycosides increase intracellular calcium and allow more calcium to enter myocardial cells.
This action causes an increased force of myocardial contraction, an increased cardiac output, and renal
perfusion that increases urine output. Cardiac glycosides also serve to slow the heart rate and decrease
conduction velocity.

Question 6

6. What is the priority nursing assessment for a patient who is about to begin digoxin therapy?
A) Blood glucose levels
B) Neurological function
C) Kidney function
D) Liver function

Answer 6

Ans: C
Feedback:
Digoxin is primarily excreted unchanged in the urine, so caution should be exercised if renal
impairment is present. Blood glucose levels and neurological and liver function would not be a priority
assessment related to digoxin therapy.

Question 7

7. A triage nurse in the emergency department is assessing a 78-year-old man. It is determined that the
   patient is experiencing severe digoxin toxicity. What drug will the nurse administer immediately?
   A) Inamrinone (Inocor)
   B) Digoxin immune Fab (Digibind)
   C) Verapamil hydrochloride (Calan)
   D) Quinidine sulfate

Answer 7

Ans: B
Feedback:
Digoxin immune Fab is an antigen-binding fragment derived from specific antidigoxin antibodies. The
drug is used for the treatment of life-threatening digoxin intoxication when serum levels are greater
than 10 ng/mL. Inamrinone is a phosphodiesterase inhibitor that acts as a cardiotonic agent. Verapamil
hydrochloride is a calcium channel blocker. Quinidine is an antiarrhythmic agent that when taken with
digoxin increases both the therapeutic and toxic effects of digoxin.

Question 8

8. The nurse is providing patient teaching to a patient who has been prescribed digoxin. The patient tells
   the nurse that she occasionally use herbals and other alternative therapies. What herb would the nurse
   warn the patient to avoid taking with digoxin?
   A) Black cohosh
   B) Ginseng
   C) Saw palmetto
   D) Valerian

Answer 8

Ans: B
Feedback:
Digoxin toxicity can occur if the drug is taken concurrently with licorice, ginseng, or hawthorn. St.
John’s wort and psyllium have been shown to decrease the effectiveness of digoxin, so that
combination should be avoided. There is no drug-to-drug interaction with black cohosh, saw palmetto,
or valerian

Question 9

9. The nurse administers an IV phosphodiesterase inhibitor. What drug will result in forming a precipitate
   if given via the same IV line without adequate flushing?
   A) Albuterol (Proventil)
   B) Nifedipine (Procardia)
   C) Furosemide (Lasix)
   D) Lovastatin (Mevacor)

Answer 9

Ans: C
Feedback: Furosemide, when given with a phosphodiesterase inhibitor, forms precipitates; therefore, this
combination should be avoided. Use alternate lines if both of these drugs are being given IV. There are
no known drug-to-drug interactions with albuterol, nifedipine, or lovastatin

Question 10

10. A 6-year-old child weighing 60 pounds has been prescribed oral digoxin (Lanoxin) 30 mcg/kg as a
    loading dose. How many milligram will she be given?
    A) 0.218 mg
    B) 0.418 mg
    C) 0.618 mg
    D) 0.818 mg

Answer 10

Ans: D
Feedback:
First, using the formula: 2.2 pounds and 60 pounds: multiplied by kg, determine the child’s weight in
kg (60/2.2 = 27.27 kg). Next, using the formula: amount of drug prescribed times weight in kg,
determine the dose in mcg the child should receive (30 multiplied by 27.27 = 0. 818 mcg). Then to
determine the amount of mg the child should receive, use the formula: 1 mg: 1,000 mcg = X mg: 818
mcg (818/1,000 = 0.818 mg).

Question 11

11. The nurse assesses the patient before administering digoxin (Lanoxin) and withholds the drug and
    notifies the physician with what finding?
    A) Respiratory rate falls below 14
    B) History reveals liver failure
    C) Pulse is 44 beats/min
    D) Blood pressure is 72/40 mm Hg

Answer 11

Ans: C
Feedback:
Monitor apical pulse for 1 full minute before administering the drug to assess for adverse effects. Hold
the dose if the pulse is less than 60 beats/min in an adult or less than 90 beats/min in an infant; retake
pulse in 1 hour. If pulse remains low, document pulse, withhold the drug, and notify the prescriber.

Question 12

12. When a drug is said to increase the force of contraction of the heart muscle, the nurse appropriately
uses what term?
A) Positive chronotropic
B) Positive inotropic
C) Negative inotropic
D) Negative dromotropic

Answer 12

Ans: B
Feedback:
Sympathetic stimulation causes an increase in heart rate, blood pressure, and rate and depth of
respirations, as well as a positive inotropic effect (increased force of contraction) on the heart and an
increase in blood volume (through the release of aldosterone). A negative inotropic effect would be one
that decreased the force of a contraction. A negative dromotropic effect is one that slows the
conduction of the impulse through the atrioventricular node. A positive chronotropic effect is one that
increases the heart rate.

Question 13

13. The nurse, caring for a patient who is receiving cardiac glycosides to treat heart failure, will teach the
    patient to follow what diet?
    A) High sodium, low potassium, high fat
    B) Low sodium, low potassium, low fat
    C) High iron, high calcium, high potassium
    D) Low sodium, high potassium, low fat

Answer 13

Ans: D
Feedback:
Restrict dietary sodium to reduce edema in patients receiving cardiac glycosides. If the patient is
hyponatremic or using a potassium-losing diuretic, increase potassium in diet, as well as limit fat intake
to reduce weight and atherogenic activity.

Question 14

14. What order for a digitalizing dose of digoxin (Lanoxin) for a 62-year-old man would the nurse consider
    appropriate and safe to administer?
    A) 1.25 mg IV now
    B) 0.75 mg orally now
    C) 0.25 mg orally every day
    D) 1 mg intramuscularly every 4 hours × 24 hours

Answer 14

Ans: B
Feedback:
Digoxin: Adult: loading dose 0.75 to 1.25 mg orally or 0.125 to 0.25 mg IV, then oral maintenance
dose of 0.125 to 0.25 mg/d; decrease dose with renal impairment

Question 15

15. After administering an IV dose of digoxin, the nurse would expect to see effects within what period of
time?
A) 30 to 120 minutes
B) 5 to 30 minutes
C) 1 hour
D) 2 hours

Answer 15

Ans: B
Feedback:
The drug has a rapid onset of action and rapid absorption (30 to 120 minutes when taken orally, 5 to 30
minutes when given IV).

Question 16

16. The patient taking digoxin (Lanoxin) has developed an infection. What antibiotic can the nurse safely
administer to this patient?
A) Zithromax
B) Erythromycin
C) Tetracycline
D) Cyclosporine

Answer 16

Ans: A
Feedback: Zithromax may be given without impacting the effects of digoxin. There is a risk of increased
therapeutic effects and toxic effects of digoxin if it is taken with verapamil, amiodarone, quinidine,
quinine, erythromycin, tetracycline, or cyclosporine. If digoxin is combined with any of these drugs, it
may be necessary to decrease the digoxin dose to prevent toxicity. If one of these drugs has been part of
a medical regimen with digoxin and is discontinued, the digoxin dose may need to be increased.

Question 17

17. The 96-year-old patient is receiving digoxin (Lanoxin) and furosemide (Lasix). In the morning, the
    patient complains of a headache and nausea. What will the nurse do first?
    A) Contact the patient’s physician immediately.
    B) Check her laboratory values and vital signs.
    C) Administer acetaminophen and Maalox.
    D) Give her clear liquids and have her lie down.

Answer 17

Ans: B
Feedback:
The nurse will check the patient’s digoxin level and electrolytes. Assessing vital signs is important
because the risk of cardiac arrhythmias could increase due to the patient’s receiving furosemide, which
is a potassium-losing diuretic. The adverse effects most frequently seen with the cardiac glycosides
include headache, weakness, drowsiness, and vision changes (a yellow halo around objects is often
reported). Gastrointestinal (GI) upset and anorexia also commonly occur. Only after checking lab
values and assessing vital signs might the nurse call the physician. Acetaminophen and Maalox would
not be indicated. Having her lie down and restricting her diet to clear liquids would be appropriate but
not the first actions.

Question 18

18. The nurse provides teaching about digoxin to the 62-year-old patient. The nurse evaluates patient
    understanding and determines further teaching is needed when the patient says she will do what?
    A) Take the medication daily in the morning.
    B) Take her pulse before taking her dose.
    C) Weigh herself daily at the same time.
    D) Take the medication with a meal.

Answer 18

Ans: D
Feedback:
Avoid administering the oral drug with food or antacids to avoid delays in absorption. The other answers are appropriate actions for the patient to take when self-administering digoxin

Question 19

19. When administering milrinone (Primacor), the nurse will assess the patient for what common adverse
effect?
A) Hypoglycemia
B) Confusion
C) Hypotension
D) Seizures

Answer 19

Ans: C
Feedback:
The adverse effects most frequently seen with these drugs are ventricular arrhythmias (which can
progress to fatal ventricular fibrillation), hypotension, and chest pain. Hypoglycemia, confusion, and
seizures are not generally adverse effects of milrinone.

Question 20

20. The nurse administers a cardiac glycoside for what therapeutic effect?
    A) To decrease cardiac output
    B) To decrease afterload
    C) To increase ventricular rate
    D) To increase the force of the contraction of the heart

Answer 20

Ans: D
Feedback:
Cardiac glycosides exert a negative cardiotonic and positive inotropic effect. They do not decrease
cardiac output, decrease afterload, or increase the ventricular rate of the heart.

Question 21

21. After administering digoxin, what assessment finding would indicate to the nurse that the drug was
having the desired effect?
A) Increased heart size
B) Increased urinary output
C) Decreased respiratory rate
D) Increased heart rate

Answer 21

Ans: B
Feedback:
As cardiac output improves, so does urinary output due to increased renal perfusion. Respiratory rate
and heart size would not be impacted by the drug, although ventricular hypertrophy is a common
finding in patients with heart failure. Heart rate would decrease as the force of contraction increases,
ejecting more blood with each contraction.

Question 22

22. What assessment finding would indicate the patient’s left-sided heart failure is worsening?
A) Increased jugular venous pressure
B) Liver enlargement
C) Increased crackles in lung fields
D) Increased pulse rate

Answer 22

Ans: C
Feedback:
Fluid may accumulate in the lungs due to left sided heart failure. Patients may evidence dyspnea,
tachypnea, and orthopnea. Right-sided failure would include increased jugular venous pressure and
liver enlargement. Pulse rate could increase or decrease depending on medications administered.

Question 23

23. Which drug is in the class of drugs called human B-type natriuretic peptides?
A) Bosentan (Tracleer)
B) Milrinone (Primacor)
C) Digoxin (Lanoxin)
D) Nesiritide (Natrecor)

Answer 23

Ans: D
Feedback: Nesiritide is the only drug currently available in a class of drugs called human B-type natriuretic
peptides. Digoxin is a cardiac glycoside. Milrinone is a phosphodiesterase inhibitor. Bosentan is an
endothelin receptor antagonist.

Question 24

24. The nurse reviews the patient’s lab results and recognizes the patient is at risk for digoxin toxicity due
to what electrolyte imbalance?
A) Hyperkalemia
B) Hypokalemia
C) Hypernatremia
D) Hyponatremia

Answer 24

Ans: B
Feedback:
Electrolyte abnormalities (e.g., increased calcium, decreased potassium, decreased magnesium) could
alter the action potential and change the effects of the drug. Hypokalemia and hypomagnesemia
increase cardiac excitability and ectopic pacemaker activity leading to dysrhythmias.

Question 25

25. What common action do both cardiac glycosides and phosphodiesterase inhibitors have in common
    related to therapeutic action?
    A) Blocking the enzyme phosphodiesterase
    B) Increasing cellular calcium
    C) Developing ventricular arrhythmias
    D) Metabolizing in the liver and excreted in the urine

Answer 25

Ans: B
Feedback:
The phosphodiesterase inhibitors block the enzyme phosphodiesterase. This blocking effect leads to an
increase in myocardial cell cyclic adenosine monophosphate (cAMP), which increases calcium levels in
the cell (Figure 44.4). Increased cellular calcium causes a stronger contraction and prolongs the effects
of sympathetic stimulation, which can lead to vasodilation, increased oxygen consumption, and
arrhythmias. Digoxin also increases intracellular calcium and allows more calcium to enter myocardial
cells during depolarization.

Question 26

26. The nurse evaluates an improvement in the patient’s heart failure (HF) status based on what assessment
finding?
A) Using fewer pillows to sleep
B) Increased skin turgor
C) Heart rate regular
D) Improved mental status

Answer 26

Ans: A
Feedback:
The degree of HF is often calculated by the number of pillows required to get relief (e.g., one-pillow,
two-pillow, or three-pillow orthopnea). Fluid overload is associated with HF so skin turgor is not an
indicator of improvement. Regular heart rate and normal cognition can be found with acute flare-ups of
HF so these findings would not indicate improvement.

Question 27

27. The nurse suspects the patient may have toxic levels of digoxin in the bloodstream when what is
assessed? (Select all that apply.)
A) Irregular heart rhythms
B) Nausea
C) Anorexia
D) Headache
E) Peripheral edema

Answer 27

Ans: A, B, C
Feedback:
Digoxin toxicity is a serious syndrome that can occur when digoxin levels are too high. The patient
may present with anorexia, nausea, vomiting, malaise, depression, irregular heart rhythms including
heart block, atrial arrhythmias, and ventricular tachycardia. Peripheral edema is indicative of heart
failure, not digoxin toxicity. Headache is not usually associated with digoxin toxicity.

Question 28

28. The patient has been prescribed inamrinone (Inocor). Before administering the drug the nurse needs to
    know the drug has what pharmacokinetic effect?
    A) Decrease in cyclic adenosine monophosphate (cAMP)
    B) Decrease in cardiac output
    C) Increase in cardiac preload
    D) Increase in cAMP

Answer 28

Ans: D
Feedback:
Inamrinone is a phosphodiesterase inhibitor that blocks the enzyme phosphodiesterase. This blocking
effect leads to an increase in myocardial cell cAMP, which increases calcium levels in the cell. These
drugs do not decrease cardiac output or increase cardiac preload.

Question 29

29. The patient has just been prescribed milrinone (Primacor). The nurse recognizes the drug is
    contraindicated due to the patient’s allergy to what?
    A) Penicillins
    B) Salicylates
    C) Opioids
    D) Bisulfites

Answer 29

Ans: D
Feedback:
Phosphodiesterase inhibitors are contraindicated in the presence of allergy to the drug or to bisulfites.
Penicillins, salicylates, and opioids have no contraindications when used with milrinone.

Question 30

30. The nurse administers a human B-type natriuretic peptide with the expectation it will have what action?
A) Decrease blood volume
B) Increase force of cardiac contraction
C) Reduce venous return
D) Lighten the heart’s workload

Answer 30

Ans: C
Feedback:
Human B-type natriuretic peptides are normally produced by myocardial cells as a compensatory
response to increased cardiac workload and increased stimulation by the stress hormones. They bind to
endothelial cells, leading to dilation and resulting in decreased venous return, peripheral resistance, and
cardiac workload. They also suppress the body’s response to the stress hormones, leading to increased
fluid loss and further decrease in cardiac workload. Diuretics decrease blood volume, cardiac
glycosides increase force of contraction, and vasodilators lighten the heart’s workload

Question 31

31. The nurse expects the patient’s heart failure (HF) is caused by what diagnosis that is responsible for
95% of the cases diagnosed?
A) Cardiomyopathy
B) Hypertension
C) Congenital anomaly
D) Coronary artery disease (CAD)

Answer 31

Ans: D
Feedback:
CAD is the leading cause of HF, accounting for approximately 95% of the cases diagnosed. CAD
results in an insufficient supply of blood to meet the oxygen demands of the myocardium.
Consequently, the muscles become hypoxic and can no longer function efficiently. When CAD evolves
into a myocardial infarction, muscle cells die or are damaged, leading to an inefficient pumping effort.
Cardiomyopathy, hypertension, and congenital anomaly are rarely associated with heart failure.

Question 32

32. The nurse prepares to administer a phosphodiesterase inhibitor by what route?
A) Oral
B) IV
C) Subcutaneous
D) Intramuscular

Answer 32

Ans: B
Feedback:Phosphodiesterase inhibitors are only given IV. They cannot be given orally, intramuscularly, or
subcutaneously.

Question 33

33. The nurse is caring for a patient who has digoxin toxicity. As the nurse assesses the changes in the
    patient’s daily activities, what finding could indicate the cause of the toxic level?
    A) The patient has been sleeping more lately.
    B) The patient took nitroglycerin for chest pain twice yesterday.
    C) The patient’s daughter brought her a bag of licorice that she has been enjoying.
    D) The patient’s intake of sodium increased lately because she’s been eating seafood.

Answer 33

Ans: C
Feedback:
Increased digoxin toxicity has been reported with ginseng, hawthorn, and licorice. Patients should be
advised to avoid these combinations. Increased sodium intake will exacerbate the patient’s heart failure,
which might explain why she is sleeping more and requiring nitroglycerin but these actions did not
contribute to the digoxin toxicity.

Question 34

34. The nurse admits a patient to the constant care unit with a digoxin level of 11 ng/mL and a serum
    potassium level of 5.2 mEq/L. Digoxin immune Fab is administered. The next day, the patient’s
    digoxin level remains elevated. What action does the nurse anticipate?
    A) Administer digoxin immune Fab again.
    B) Administer a reduced dosage of digoxin.
    C) Continue to monitor the patient’s digoxin level daily.
    D) Notify the health care provider of the elevated level.

Answer 34

Ans: C
Feedback:
Serum digoxin levels will be very high and unreliable for about 3 days after the digoxin immune Fab
infusion because of the high levels of digoxin in the blood. The patient should not be redigitalized for
several days to 1 week after digoxin immune Fab has been used, because of the potential of fragments
remaining in the blood. There is no need to notify the health care provider or to administer digoxin
immune Fab again.

Question 35

35. The nurse is preparing to administer a digitalizing dosage of digoxin to a geriatric patient. What factors will the nurse assess for first to avoid digoxin toxicity? (Select all that apply.)
A) Renal function
B) Low body mass
C) Hydration
D) Assessment of pulse
E) Cognitive function

Answer 35

Ans: A, B, C
Feedback:
Factors that may contribute to elevated digoxin levels include impaired renal function, low body mass,
and dehydration. Assessment of pulse and cognitive function are always important when caring for a
geriatric patient, but they will not contribute to elevated digoxin levels.