Ch. 38 Heart Failure

While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient‘s bed elevated 45 degrees. What does this finding indicate?

Increased ventricular filling pressure

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?

Reduced dyspnea with the head of bed at 30 degrees

Which topic will the nurse plan to include in discharge teaching for a patient who has heart failure with reduced ejection fraction (HFrEF)?

Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors

IV sodium nitroprusside is prescribed for a patient with acute pulmonary edema. Which reassessment finding indicates that the nurse should decrease the rate of nitroprusside infusion?

Systolic BP below 90 mm Hg

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?

Paroxysmal nocturnal dyspnea

Which statement by a patient newly diagnosed with heart failure indicates to the nurse that teaching was effective?

“I will call the clinic if my weight goes up 3 pounds in a week.”

Which foods would the nurse recommend limiting for a patient on a 2000-mg sodium diet?

Yogurt and milk products

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?

Referral to a home health care agency

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?

Angiotensin-converting enzyme (ACE) inhibitor

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?

“The suitability of a heart transplant depends on many factors.”

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?

B-type natriuretic peptide

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?

“I will call for help when I need to get up to use the bathroom.”

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication would the nurse question before giving?

Carvedilol (Coreg) 3.125 mg

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?

Auscultate the breath sounds.

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?

Assess the patient for manifestations of acute heart failure

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?

Give PRN IV morphine sulfate 4 mg.

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient would the nurse assess first?

A patient who has new-onset confusion and restlessness.

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires immediate action by the nurse?

O2 saturation of 88%

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?

Serum potassium level 3.0 mEq/L after 1 week of therapy

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?

Blood pressure 88/42 mm Hg

A patient who is receiving dobutamine for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action would be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)?

Monitor the patient‘s blood pressure and heart rate every hour.

After receiving change-of-shift report, which patient would the nurse assess first?

Patient who is taking digoxin and has a potassium level of 3.1 mEq/L

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which data would indicate to the nurse that the goals of IABP treatment are being met?

Cardiac output (CO) of 5 L/min

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?

Monitor the patient‘s urinary output every hour.

While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. Which action would the nurse include in the plan of care for this patient?

Monitoring the incision for signs of infection