Heart failure ch 34 Flashcards
(25 cards)
While assessing a 68-yr-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient’s bed elevated 45 degrees. The nurse knows this finding indicates
a. decreased fluid volume. c. increased right atrial pressure.
b. jugular vein atherosclerosis. d. incompetent jugular vein valves.
C
The nurse is caring for a patient who is receiving IV furosemide (Lasix) 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. Reduction in patient complaints of chest pain
d. Reduced dyspnea with the head of bed at 30 degrees
D
Which topic will the nurse plan to include in discharge teaching for a patient with heart failure with reduced ejection fraction (HFrEF)?
a. Need to begin an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Importance of making an annual appointment with the health care provider
d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
D
IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate down if the patient develops
a. ventricular ectopy. c. a systolic BP below 90 mm Hg.
b. a dry, hacking cough. d. a heart rate below 50 beats/min.
C
A patient who has chronic heart failure tells the nurse, “I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!” The nurse will document this assessment finding as
a. orthopnea. c. paroxysmal nocturnal dyspnea.
b. pulsus alternans. d. acute bilateral pleural effusion.
C
During a visit to a 78-yr-old patient with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of “feeling too tired to get out of bed.” Based on these data, a correct nursing diagnosis for the patient is
a. activity intolerance related to fatigue.
b. impaired skin integrity related to edema.
c. disturbed body image related to weight gain.
d. impaired gas exchange related to dyspnea on exertion.
A
The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that
a. she will take furosemide (Lasix) every day at bedtime.
b. the nitroglycerin patch is to be used when chest pain develops.
c. she will call the clinic if her weight goes up 3 pounds in 1 week.
d. an additional pillow can help her sleep if she is short of breath at night.
C
When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include
a. canned and frozen fruits. c. fresh or frozen vegetables.
b. yogurt and milk products. d. eggs and other high-protein foods.
B
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include
a. limit dietary sources of potassium.
b. take the hydrochlorothiazide before bedtime.
c. notify the health care provider if nausea develops.
d. take the digoxin if the pulse is below 60 beats/min.
C
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.” When planning for the patient’s discharge the nurse will facilitate a
a. plan for around-the-clock care.
b. consultation with a psychologist.
c. transfer to a long-term care facility.
d. referral to a home health care agency.
D
Following an acute myocardial infarction, a previously healthy 63-yr-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about
a. -Adrenergic blockers.
b. calcium channel blockers.
c. digitalis and potassium therapy regimens.
d. angiotensin-converting enzyme (ACE) inhibitors.
D
A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most accurate?
a. “Your heart failure has not reached the end stage yet.”
b. “You could not manage the multiple complications of that surgery.”
c. “The suitability of a heart transplant for you depends on many factors.”
d. “Because you have diabetes, you would not be a heart transplant candidate.”
C
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 c. B-type natriuretic peptide
b. Arterial blood gases d. 12-lead electrocardiogram
C
Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?
a. Monitor blood pressure frequently.
b. Encourage patient to ambulate in room.
c. Titrate nesiritide slowly before stopping.
d. Teach patient about home use of the drug.
A
A patient with 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 will be sure to take the medication with food.”
b. “I will need to eat more potassium-rich foods in my diet.”
c. “I will call for help when I need to get up to use the bathroom.”
d. “I will expect to feel more short of breath for the next few days.”
C
A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving?
a. captopril 25 mg c. digoxin (Lanoxin) 0.125 mg
b. furosemide (Lasix) 60 mg d. carvedilol (Coreg) 3.125 mg
D
A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse do first?
a. Auscultate the abdomen. c. Auscultate the breath sounds.
b. Check the capillary refill. d. Ask about the patient’s allergies.
C
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. The nurse’s priority action will be to
a. have the patient recall the dietary intake for the past 3 days.
b. ask the patient about the use of the prescribed medications.
c. assess the patient for clinical manifestations of acute heart failure.
d. teach the patient about the importance of restricting dietary sodium.
C
A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been ordered for the patient. The nurse’s priority action will be to
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
After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first?
a. A patient who reported dizziness after receiving the first dose of captopril
b. A patient who is cool and clammy, with new-onset confusion and restlessness
c. A patient who has crackles bilaterally in the lung bases and is receiving oxygen.
d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62
B
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse?
a. O2 saturation of 88% c. Heart rate of 106 beats/min
b. Weight gain of 1 kg (2.2 lb) d. Urine output of 50 mL over 2 hours
A
A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril for the management of heart failure. Which assessment 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
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 56 beats/min
c. Complaints of increased fatigue
d. Blood pressure (BP) of 88/42 mm Hg
D
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 will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
a. Teach the patient the reasons for remaining on bed rest.
b. Change the peripheral IV site according to agency policy.
c. Monitor the patient’s blood pressure and heart rate every hour.
d. Titrate the rate to keep the systolic blood pressure >90 mm Hg.
C
