Chapter 38: Heart Failure [MED-SURGE FINAL EXAM]

The nurse is administering a dose of digoxin to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom?

Muscle aches

Constipation

Loss of appetite

Pounding headache

Loss of appetite

Rationale:

Anorexia, nausea, vomiting, blurred or yellow vision, and dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

The patient with chronic heart failure (HF) is being discharged from the hospital. Which information would the nurse emphasize to prevent progression of the disease to acute decompensated heart failure (ADHF)?

Weigh yourself once a week.

Take medications as prescribed.

Use oxygen when feeling short of breath.

Do all of the daily activity in the morning.

Take medications as prescribed.

Rationale:

The goal for the patient with chronic HF is to avoid exacerbations and hospitalization.

Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Daily weights are recommended to monitor fluid balance and allow for prompt response.

After having a myocardial infarction (MI), a patient has jugular venous distention (JVD), weight gain, peripheral edema, and a heart rate of 108 beats/min. Which type of heart failure (HF) would the nurse suspect?

Chronic HF

Left-sided HF

Right-sided HF

Acute decompensated HF

Right-sided HF

Rationale:

An MI is a primary cause of heart failure. The JVD, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

The home care nurse visits a patient with chronic heart failure (HF). Which assessment findings would indicate acute decompensated heart failure (ADHF)?

Fatigue, orthopnea, and dependent edema

Severe dyspnea and blood-streaked, frothy sputum

Temperature is 100.4°F and pulse is 102 beats/min

Respirations 26 breaths/min despite oxygen by nasal cannula

Severe dyspnea and blood-streaked, frothy sputum

Rationale:

ADHF can manifest as pulmonary edema. This is an acute, life-threatening situation, in which the lung alveoli become filled with serosanguineous fluid.

Manifestations can also include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths/min, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum.

Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

An older adult patient with chronic heart failure (HF) and atrial fibrillation asks the nurse why an anticoagulant has been prescribed to continue at home. Which response would the nurse provide?

“The medication prevents blood clots from forming in your heart.”

“The medication dissolves clots that develop in your coronary arteries.”

“The medication reduces clotting by decreasing serum potassium levels.”

“The medication increases your heart rate so that clots do not form in your heart.”

“The medication prevents blood clots from forming in your heart.”

Rationale:

Chronic HF causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs.

Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants.

Which finding would the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure (HF)?

Acute anxiety

Hypotension and tachycardia

Peripheral edema and weight gain

Paroxysmal nocturnal dyspnea (PND)

Hypotension and tachycardia

Rationale:

Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension.

PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

The nurse prepares to administer digoxin to a patient admitted with influenza and a history of chronic heart failure (HF). Which result would the nurse review before giving the medication?

Prothrombin time

Urine specific gravity

Serum potassium level

Hemoglobin and hematocrit

Serum potassium level

Rationale:

Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity.

Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit would not require holding the digoxin dose.

A patient with a recent diagnosis of heart failure (HF) has been prescribed furosemide. Which outcome would demonstrate medication effectiveness?

Reduced preload

Decreased afterload

Enhanced vasodilation

Increased contractility

Reduced preload

Rationale:

Diuretics such as furosemide are used in the treatment of heart failure to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload.

• They do not directly influence afterload, contractility, or vessel tone.

A patient is scheduled for a heart transplant. What is the major cause of death beyond the first year after a heart transplant?

Infection

Acute rejection

Immunosuppression

Cardiac vasculopathy

Cardiac vasculopathy

Rationale:

Beyond the first year after a heart transplant, cancer (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease) are the major causes of death.

During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient’s risk of an infection.

At a clinic visit, the nurse provides dietary teaching for a patient recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement?

“I will limit the amount of milk and cheese in my diet.”

“I can add salt when cooking foods but not at the table.”

“I will take an extra diuretic pill when I eat a lot of salt.”

“I can have unlimited amounts of foods labeled as reduced sodium.”

“I will limit the amount of milk and cheese in my diet.”

Rationale:

Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet.

Salt should not be added during food preparation or at the table. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake. Foods labeled as reducedsodium contain at least 25% less sodium than regular.

A patient admitted with heart failure (HF) is anxious and reports shortness of breath. Which actions would the nurse take? (Select all that apply.)

Administer prescribed morphine sulfate.

Place patient in a semi-Fowler’s position.

Position patient on left side with head of bed flat.

Instruct patient on the use of relaxation techniques.

Use a calm, reassuring approach while talking to patient.

Administer prescribed morphine sulfate.

Place patient in a semi-Fowler’s position.

Instruct patient on the use of relaxation techniques.

Use a calm, reassuring approach while talking to patient.

Rationale:

• Morphine sulfate reduces anxiety and may assist in reducing dyspnea.

• The patient should be positioned in semi-Fowler’s position to improve ventilation that will reduce anxiety.

• Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

Which information would the nurse provide to a patient about the use of a nitroglycerin patch?

Avoid drugs to treat erectile dysfunction.

Increase diet intake of high-potassium foods.

Take an over-the-counter H₂-receptor blocker.

Avoid nonsteroidal antiinflammatory drugs (NSAIDS).

Avoid drugs to treat erectile dysfunction.

Rationale:

The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. NSAIDs do not pose a risk in combination with nitrates. There is no need to take an H₂-receptor blocker or increase the dietary intake of high-potassium foods.

A patient with a long-standing history of heart failure (HF) recently qualified for hospice care. Which measure would the nurse now prioritize when providing care for this patient?

Taper the patient off his current medications.

Continue education for the patient and his family.

Pursue experimental therapies or surgical options.

Choose interventions to promote comfort and prevent suffering.

Choose interventions to promote comfort and prevent suffering.

Rationale:

The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not used in the care of hospice patients.

The nurse is preparing to administer digoxin to a patient with heart failure (HFLaboratory results include the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What is the priority action by the nurse?

Withhold the daily dose until the following day.

Withhold the dose and report the potassium level.

Give the digoxin with a salty snack, such as crackers.

Give the digoxin with extra fluids to dilute the sodium level.

Withhold the dose and report the potassium level.

Rationale:

The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity.

For this reason, the nurse should withhold the dose and wait for the potassium level to normalize. The provider may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

An asymptomatic patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before dangling the patient on the bedside, what would the nurse assess first?

Urine output

Heart rhythm

Breath sounds

Blood pressure

Blood pressure

Rationale:

The nurse would evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases.

If the patient’s blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler’s position and use other measures to improve gas exchange.

Which assessment is the priority of the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure?

Urine output

Lung sounds

Blood pressure

Respiratory rate

Blood pressure

Rationale:

Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.

A patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first?

Review urinary output for the previous 24 hours.

Restrict the patient’s oral fluid intake to 500 mL/day.

Assist the patient to a sitting position with arms on the overbed table.

Teach the patient to use pursed-lip breathing until the dyspnea subsides.

Assist the patient to a sitting position with arms on the overbed table.

Rationale:

• The nurse should place the patient with ADHF in a high Fowler’s position with the feet horizontal in the bed or dangling at the bedside.

• This position helps decrease venous return because of the pooling of blood in the extremities.

• This position also increases the thoracic capacity, allowing for improved ventilation.

Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.