Blood-streaked frothy sputum.
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The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? B Severe dyspnea and blood-streaked, frothy sputum
answer
Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths per minute, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum.
question
A 54-year-old male 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? C Assist the patient to a sitting position with arms on the overbed table.
answer
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.
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A 70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed for her to continue at home. Which response by the nurse is accurate? A "The medication prevents blood clots from forming in your heart."
answer
Chronic heart failure causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria.
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The nurse prepares to administer digoxin (Lanoxin) 0.125 mg to an 82-year-old man admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication? C Serum potassium level
answer
Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity.
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At a clinic visit, the nurse provides dietary teaching for a 56-year-old woman who was recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement? A "I will limit the amount of milk and cheese in my diet."
answer
Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet.
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The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? D Anorexia and nausea
answer
Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity.
question
The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? B Withhold the dose and report the potassium level.
answer
The normal potassium level is 3.5 to 5.0 mEq/L.
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What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? C Blood pressure
answer
the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.
question
A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? A Administer ordered morphine sulfate. B Position patient in a semi-Fowler's position. D Instruct patient on the use of relaxation techniques. E Use a calm, reassuring approach while talking to patient.
answer
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.
question
A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? D Choose interventions to promote comfort and prevent suffering.
answer
The central focus of hospice care is the promotion of comfort and the prevention of suffering.
question
What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with heart failure? B Hypotension and tachycardia
answer
Dopamine is a ?-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability.
question
A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? A Reduce preload.
answer
Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload.
question
A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. What should this patient be taught to avoid? B Drugs to treat erectile dysfunction
answer
The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death.
question
A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside, what should the nurse assess first? D Blood pressure
answer
The nurse should 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.
question
The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply)? A Left ventricular function is documented. D Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge E Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen
answer
The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.
question
After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? D Right-sided HF
answer
An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.
question
Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? D Cardiac vasculopathy
answer
Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are the major causes of death.
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The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to ADHF? A Take medications as prescribed.
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The goal for the patient with chronic HF is to avoid exacerbations and hospitalization.
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While assessing a 68-year-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 c. increased right atrial pressure.
answer
jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure.
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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? d. Reduced dyspnea with the head of bed at 30 degrees
answer
Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees
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Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%? c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
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The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) ;40% receive an ACE inhibitor to decrease the progression of heart failure.
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IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops c. a systolic BP ;90 mm Hg.
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Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension.
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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 c. paroxysmal nocturnal dyspnea.
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Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation.
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During a visit to a 78-year-old 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, the best nursing diagnosis for the patient is a. activity intolerance related to fatigue.
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The patient's statement supports the diagnosis of activity intolerance.
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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 c. all the clinic if her weight goes from 124 to 128 pounds in a week.
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Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week.
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When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include d. milk, yogurt, and other milk products.
answer
Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily.
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The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include c. notify the health care provider if nausea develops.
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Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary.
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While admitting an 82-year-old 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 c. referral to a home health care agency.
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The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed.
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Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about d. angiotensin-converting enzyme (ACE) inhibitors.
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ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure.
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A 53-year-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 appropriate? b. "The choice of a patient for a heart transplant depends on many different factors."
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Indications for a heart transplant include end-stage heart failure (Stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered.
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Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? c. B-type natriuretic peptide
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B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure.
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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.
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Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension.
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A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? c. "I will call for help when I need to get up to use the bathroom."
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Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose.
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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? d. Carvedilol (Coreg) 3.125 mg
answer
Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure.
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A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? c. Auscultate the breath sounds.
answer
This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring.
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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-pound weight gain in the last 3 days. The nurse's priority action will be to. c. assess the patient for clinical manifestations of acute heart failure.
answer
The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening.
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A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurse's priority action will be to a. give IV morphine sulfate 4 mg.
answer
Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange.
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After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. A patient who is cool and clammy, with new-onset confusion and restlessness
answer
The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management.
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Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a. Oxygen saturation of 88%
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A decrease in oxygen saturation to less than 92% indicates hypoxemia.
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A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? c. Serum potassium level 3.0 mEq/L after 1 week of therapy
answer
Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias.
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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? c. Blood pressure (BP) of 88/42 mm Hg
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The patient's BP indicates that the dose of metoprolol may need to be decreased because of hypotension.
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A patient who is receiving dobutamine (Dobutrex) 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)? c. Monitor the patient's blood pressure and heart rate every hour.
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An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN.
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After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L
answer
The patient's low potassium level increases the risk for digoxin toxicity and potentially fatal dysrhythmias
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Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)? a. How to take and record daily weight c. Date and time of follow-up appointment d. Symptoms indicating worsening heart failure e. Actions and side effects of prescribed medications
answer
The Joint Commission Core Measures state that patients should be taught about prescribed medications, follow-up appointments, weight monitoring, and actions to take for worsening symptoms. Patients with heart failure are encouraged to begin or continue aerobic exercises such as walking, while self-monitoring to avoid excessive fatigue.
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The nurse recognizes that primary manifestations of systolic failure include: a. decreased EF and increased PAWP
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Systolic heart failure results in systolic failure in the left ventricle (LV). The LV loses its ability to generate enough pressure to eject blood forward through the aorta.
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A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is: c. neurohormonal response
answer
The following mechanisms in heart failure lead to inappropriate fluid retention and additional workload of the heart: activation of the renin-angiotensin-aldosterone system (RAAS) cascade and release of antidiuretic hormone from the posterior pituitary gland in response to low cerebral perfusion pressure that results from low cardiac output.
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You are caring for a patient with ADHF who is receiving IV dobutamine (Dobutrex). You know that this drug is ordered because it (select all that apply): c. improves contractility e. works on the B1-receptors in the heart.
answer
Dobutamine (Dobutrex) has a positive chronotropic effect and increases heart rate and improves contractility. It is a selective ?-adrenergic agonist and works primarily on the ?1-adrenergic receptors in the heart. It is frequently used in the short-term management of acute decompensated heart failure (ADHF).
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A patient with chronic HF and atrial fibrillation is treated with a digitalis glycoside and a loop diuretic. To prevent possible complications of this combination of drugs, what does the nurse need to do (select all that apply)? a. Monitor serum potassium levels b. teach the patient how to take a pulse rate.
answer
Hypokalemia, which can be caused by the use of potassium-depleting diuretics (e.g., thiazides, loop diuretics), is one of the most common causes of digitalis toxicity. Low serum levels of potassium enhance the action of digitalis, causing a therapeutic dose to achieve toxic levels. Hypokalemia can also precipitate dysrhythmias. Monitoring the serum potassium levels of patients receiving digitalis preparations and potassium-depleting diuretics is essential. Patients taking digitalis preparations should be taught how to measure their pulse rate because bradycardia and atrioventricular blocks are late signs of digitalis toxicity. In addition, patients should know what pulse rate would necessitate a call to the health care provider.
question
Patients with a heart transplantation are at risk for which complications in the first year after transplantation (select all that apply)? b. infection c. rejection e. sudden cardiac death
answer
A variety of complications can occur after heart transplantation. In the first year after transplantation, the major causes of death are acute rejection and infection. Heart transplant recipients also are at risk for sudden cardiac death. Later, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are major causes of death.
question
The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? d. Anorexia and nausea
answer
Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity.
question
The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? b. Withhold the dose and report the potassium level.
answer
The normal potassium level is 3.5 to 5.0 mEq/L.
question
What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? c. Blood pressure
answer
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.
question
A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? a. Administer ordered morphine sulfate. b. Position patient in a semi-Fowler's position. d. Instruct patient on the use of relaxation techniques. e. Use a calm, reassuring approach while talking to patient.
answer
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.
question
A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? d. Choose interventions to promote comfort and prevent suffering.
answer
The central focus of hospice care is the promotion of comfort and the prevention of suffering.
question
What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with heart failure? b. Hypotension and tachycardia
answer
Dopamine is a ?-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability.
question
A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? a. Reduce preload.
answer
Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload.
question
A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. What should this patient be taught to avoid? b. Drugs to treat erectile dysfunction
answer
The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death.
question
A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside, what should the nurse assess first? d. Blood pressure
answer
The nurse should 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.
question
The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply)? a. Left ventricular function is documented. d. Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge e. Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen
answer
The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF.
question
After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? d. Right-sided HF
answer
An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.
question
Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? d. Cardiac vasculopathy
answer
Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are the major causes of death.
