Chapter 34: Heart Failure Lewis: Medical-Surgical Nursing, 10th Edition

MULTIPLE CHOICE 1. 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. ANS: C The 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. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis. DIF: Cognitive Level: Understand (comprehension) REF: 739 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. 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 ANS: D 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. The other assessment data may also indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient’s response. DIF: Cognitive Level: Analyze (analysis) REF: 742 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 3. 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 ANS: D This study source was downloaded by from CourseH on :53:42 GMT -05:00 CHAPTER 34 : HEART FAILURE The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction below 40% should receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually. DIF: Cognitive Level: Apply (application) REF: 737 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 4. 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. ANS: C Sodium nitroprusside is a potent vasodilator and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy. DIF: Cognitive Level: Apply (application) REF: 745 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 5. 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. ANS: C 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. Pulsus alternans is the alteration of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period. DIF: Cognitive Level: Understand (comprehension) REF: 742 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 6. 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. ANS: A This study source was downloaded by from CourseH on :53:42 GMT -05:00 The patient’s statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for additional patient problems. DIF: Cognitive Level: Apply (application) REF: 750 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 7. 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. ANS: C 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 lb in 2 days or 3 to 5 lb in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an “as needed” basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops rather than just compensating by further elevating the head of the bed. DIF: Cognitive Level: Apply (application) REF: 744 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 8. 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. ANS: B Yogurt and milk products (e.g., cheese) naturally contain a significant amount of sodium, and the intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. The other foods listed have minimal levels of sodium and can be eaten without restriction. DIF: Cognitive Level: Apply (application) REF: 749 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. 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. ANS: C