Week 3 CHF Flashcards
A client with left sided heart failure asks the nurse why it is so difficult for him to breathe while lying flat. What is the nurse’s best response?
Instruct the client to take his diuretic as ordered.
Explain that with his condition, blood is backing up into the lungs and that it may help to sleep while propped on pillows.
Explain that blood is backing up into the peripheral circulation and instruct the client on coughing and deep breathing.
Ask if the client suddenly wakes up with a feeling of breathlessness at night.
Explain that with his condition, blood is backing up into the lungs and that it may help to sleep while propped on pillows.
This answer is correct because the client is experiencing PND. The nurse gives a thorough explanation of why the client is experiencing dyspnea when lying flat as well as gives specific instructions on how to relieve this dyspnea at night.
A client admitted with an exacerbation of congestive heart failure (CHF) will have the goals to:
Increase preload, increase afterload, decrease cardiac output.
Decrease preload, decrease afterload, decrease cardiac output.
Increase preload, increase afterload, increase cardiac output.
Decrease preload, decrease afterload, increase cardiac output.
Decrease preload, decrease afterload, increase cardiac output.
The focus of this question is asking the nurse to identify the appropriate goals for a client admitted for treatment of exacerbation of congestive heart failure. Congestive heart failure results from a heart that is not pumping forward adequately enough to perfuse the body/ lungs. The goals for these clients are to decrease preload (venous return), afterload (resistance the heart must overcome in order to pump effectively), and increase cardiac output.
The nurse is caring for a client with congestive heart failure. The client’s blood pressure has been trending down with the most recent result being 78/48. The nurse will take action to improve the blood pressure in order to prevent:
- intra-renal failure.
- pre-renal failure.
- post-renal failure.
- chronic renal failure.
- pre-renal failure.
This answer is correct because hypotension and congestive heart failure prevent adequate renal perfusion and are thus considered pre-renal etiologies for renal injury.
A client has jugular venous distention (JVD), hepatomegaly, and peripheral edema. The client is exhibiting signs of:
left sided heart failure.
septal failure.
biventricular failure.
right-sided heart failure.
right-sided heart failure.
The focus of this question is asking the nurse to identify signs of right sided heart failure. When the right side of the heart fails, blood backs up into the periphery or systemic circulation. JVD, hepatomegaly, and peripheral edema are manifestations associated with right sided heart failure.
Which signs and symptoms indicate that a client is experiencing left-sided heart failure? Select all that apply.
Ascites
Crackles
Pitting edema
Frothy pink sputum
Jugular vein distention
Crackles
Frothy pink sputum
Left-sided heart failure causes fluid to back up into the lungs. Manifestations of left-sided heart failure include crackles, frothy pink sputum, dyspnea, and orthopnea.
The nurse is caring for a client with heart failure who says, “My doctor is saying that I have right-sided heart failure, but how is that different from left-sided heart failure?” How should the nurse reply?
“Left-sided heart failure occurs when the left atrium becomes stiff, which affects the ability of the right atrium to contract.”
“Left-sided heart failure means your left ventricle is not pumping effectively, which can cause fluid to back up into your lungs.”
“Heart failure typically begins on the right side but can occur on either side of the heart, and it prevents oxygen from reaching the lungs.”
“Heart failure begins in the right side of the heart when the ventricle hardens, but symptoms are not typically present.”
“Left-sided heart failure means your left ventricle is not pumping effectively, which can cause fluid to back up into your lungs.”
Which nursing diagnosis should the nurse assign the highest priority for a client with left-sided heart failure?
Activity intolerance related to weakness of the legs
Anxiety related to shortness of breath
Deficient knowledge related to medication regimen
Excess fluid volume related to excess fluid in the lungs
Excess fluid volume related to excess fluid in the lungs
The nurse is reviewing the chart of a client with chronic heart failure. Which finding(s) should the nurse identify as long-term complications of the disease process? Select all that apply.
A. Swelling in bilateral feet and ankles
B. B-type natriuretic peptide (BNP) of 950 pg/ml
C. Pain in the left lower abdomen
D. Ejection fraction (EF) of 35%
E. Heart rate of 77
A. Swelling in bilateral feet and ankles
B. B-type natriuretic peptide (BNP) of 950 pg/ml
D. Ejection fraction (EF) of 35%
A community health nurse is conducting an education session with a group of adults about risk factors associated with developing heart failure. Which factor(s) should the nurse include in the teaching? Select all that apply.
A. Dysfunctional kidneys
B. Physical trauma or surgery
C. Obsessive-compulsive behaviors
D. Chronic high blood pressure
E. Blocked arteries of the heart
A. Dysfunctional kidneys
D. Chronic high blood pressure
E. Blocked arteries of the heart
Which finding indicates that treatment for left-sided heart failure has been successful?
The client has had a urinary output of 78 mL in 12 hours.
The client is unable to move from the bed to chair due to shortness of breath.
The client can sleep at night with the head of the bed at 90 degrees.
The client’s oxygen is decreased to 0.5L from 3L.
The client’s oxygen is decreased to 0.5L from 3L.
The dayshift nurse is completing bedside rounds with the oncoming nurse for a client diagnosed with left-sided heart failure. Which finding should the oncoming nurse report to the healthcare provider immediately?
Oxygen saturation level of 95% on 2L of oxygen via nasal cannula
Decreased crackles bilaterally
A frothy, dark pink sputum sample
Respiratory rate of 22 immediately after walking around in the hallway
A frothy, dark pink sputum sample
Which statement(s) should the nurse include when teaching a client with left-sided heart failure to prevent future exacerbations? Select all that apply.
A. “Take your lisinopril and furosemide as ordered.”
B. “Eat a low-salt diet to prevent fluid retention.”
C. “Weigh yourself at the same time each day.”
D. “Eat lots of high-cholesterol foods to prevent heart disease.”
E. “Increase calcium intake to prevent heart failure.”
F. “Monitor your fluid intake to prevent fluid overload.”
A. “Take your lisinopril and furosemide as ordered.”
B. “Eat a low-salt diet to prevent fluid retention.”
C. “Weigh yourself at the same time each day.”
F. “Monitor your fluid intake to prevent fluid overload.”
The nurse on the medical-surgical unit is reviewing the electronic health record (EHR) of a newly admitted client diagnosed with heart failure. Which findings should the nurse associate with heart failure?
Shortness of breath, cough, and heart rate of 110
Oxygen of 95% on room air, headache, and nausea
Temperature of 97° F (36.1° C), venous ulcers, and respirations of 20
Severe back pain, difficulty walking, and shallow breathing
Shortness of breath, cough, and heart rate of 110
The nurse is reviewing the admission orders for a client with left-sided heart failure. Which order(s) should the nurse question? Select all that apply.
A. High-cholesterol, high-fat diet
B. Sodium-restricted diet
C. Notify physician of weight change > 10 lbs/week
D. Furosemide 20 mg by mouth daily
E. Continuous oxygen at 2L via nasal cannula
A. High-cholesterol, high-fat diet
C. Notify physician of weight change > 10 lbs/week
A client recently diagnosed with left-sided heart failure is in the outpatient clinic for shortness of breath. Which additional assessment finding indicates that the client may be experiencing worsening of the condition?
Respiratory rate of 12 and shoulder pain 7/10
Crackles auscultated bilaterally and pink, frothy sputum
Urine output of 1000 mL and increased episodes of vomiting
Heart rate of 75 and blood pressure of 105/68
Crackles auscultated bilaterally and pink, frothy sputum
