Deck 26: Nursing Care of Patients With Heart Failure

Question 1

The nurse is collecting data for an anxious patient who reports dyspnea. Data collection findings include diaphoresis; retractions; pink, frothy sputum; blood pressure 174/86 mm Hg; pulse 116 beats/min; and respirations 32/min. After morphine is given, which of these findings indicate the patient is having a desired response to the morphine?

A)Slow, shallow respirations
B)Lethargy
C)Reduced blood pressure
D)Increased pulmonary pressures

Answer 1

Reduced blood pressure

Question 2

A patient is receiving potassium (K-Lor) 10 mEq/L, bumetanide (Bumex) 20 mg, and digoxin (Lanoxin) 0.125 mg orally. The patient's morning potassium level is 4.2 mEq/L. The nurse is scheduled to give K-Lor 10 mEq/L now. Which of these actions should the nurse take?

A)Give K-Lor as scheduled now.
B)Hold the next dose of digoxin.
C)Hold K-Lor.
D)Inform the registered nurse.

Answer 2

Give K-Lor as scheduled now.

Question 3

The nurse is contributing to a plan of care for a patient who has heart failure. What would be the major goal of nursing management for the patient?

A)Increase fluid intake.
B)Promote a decrease in cardiac output.
C)Reduce the workload of the heart.
D)Increase venous return to the heart.

Answer 3

Reduce the workload of the heart.

Question 4

The nurse is assisting with the care of a patient who is experiencing pulmonary edema. Which of these findings would the nurse expect to observe?

A)Sacral edema
B)Pink, frothy sputum
C)Pedal edema
D)Nausea/vomiting

Question 5

A patient who is to receive bumetanide (Bumex) in 1 hour has less ankle edema and neck vein distention than earlier. What action should the nurse take?

A)Notify the registered nurse.
B)Hold the Bumex.
C)Give the Bumex early.
D)Give the scheduled Bumex.

Question 6

The nurse is caring for a patient who is to receive furosemide (Lasix). Which of these laboratory results should the nurse review first?

A)Serum sodium
B)Serum potassium
C)Urine sodium
D)Urine potassium

Question 7

A patient is receiving digoxin (Lanoxin) daily. Which of the following symptoms would the nurse need to report for follow-up related to the digoxin?

A)Skin flushing
B)Constipation
C)BP 118/68 mm Hg
D)Anorexia

Question 8

The nurse is contributing to a plan of care for a patient who has had a 5 pound weight gain in 2 days, pitting edema of the ankles, lung crackles, and distended neck veins. Which nursing diagnosis would be given priority in the plan of care?

A)Noncompliance
B)Urinary Retention
C)Excess Fluid Volume
D)Ineffective Health Maintenance

Question 9

The nurse is caring for a newly admitted patient who has heart failure and a "do not resuscitate" order. The patient gets up to go to the bathroom when activity orders are for bedrest. When told not to get out of bed per physician orders, the patient becomes angry. What would be the best way for the nurse to handle this situation?

A)Obtain a bedside commode.
B)Walk the patient to the bathroom.
C)Call for help while holding the patient in bed.
D)Obtain a bedpan for the patient to use.

Question 10

The nurse is collecting data for a patient who is receiving digoxin (Lanoxin), 0.125 mg daily. Which of these findings would indicate to the nurse that the patient is experiencing side effects of the medication?

A)Skin flushing
B)Bradycardia
C)Double vision
D)Constipation

Question 11

The nurse is caring for a patient who appears to have increased dyspnea. Bilateral crackles are noted on auscultation. Which of the following actions should the nurse take?

A)Teach the patient how to use oral suctioning.
B)Help the patient lie on the right side.
C)Raise the head of the bed to 90 degrees.
D)Notify the registered nurse.

Question 12

A home health nurse is collecting data for a patient who has heart failure and diabetes. The nurse obtains the following data: subjective-"I feel strange"; objective-blood pressure 172/94 mm Hg, pulse 112 beats/min, respirations 22/min; heart rhythm regular; coarse crackles in lower lung bases. What action should the nurse take?

A)Assist patient to bed for a nap.
B)Consult the registered nurse.
C)Recheck vital signs in 30 minutes.
D)Give the patient orange juice.

Question 13

The nurse is collecting data for a patient admitted for heart failure who has clavicle muscle retractions, nostril flaring, and labored breathing. Vital signs are as follows: blood pressure 162/84 mm Hg, pulse 120 beats/min, and respirations 32/min. Which patient data would require immediate action be taken?

A)Quiet, shallow respirations
B)Use of neck accessory muscles
C)Jaw jutting forward to inhale
D)Leaning on the over-bed table

Question 14

The nurse is assisting with the care of a patient who receives bumetanide (Bumex) 3 mg intravenously. Which of these actions should the nurse take after this medication is administered?

A)Weigh the patient in 2 hours.
B)Monitor urine output.
C)Watch for leg cramps, and medicate if necessary.
D)Listen to heart sounds for irregular heart rhythms.

Question 15

The nurse is to give a patient furosemide (Lasix) 20 mg orally. The patient's potassium level is 3 mEq/L. What action should the nurse take?

A)Consult the RN before giving Lasix.
B)Hold this scheduled dose of the Lasix.
C)Give the Lasix 30 minutes early.
D)Give the Lasix as scheduled now.

Question 16

The nurse is collecting data for a patient who is in left-sided heart failure. Which of these findings would the nurse document?

A)Dyspnea, cough
B)Hypokalemia, edema
C)Enlarged liver, distended neck veins
D)Edema, distended neck veins

Question 17

A patient is receiving potassium (K-Lor) 20 mEq/L, furosemide (Lasix) 20 mg, and digoxin (Lanoxin) 0.125 mg orally. The patient's potassium level is 5.8 mEq/L. The nurse is scheduled to give K-Lor 20 mEq/L now. Which of these actions should the nurse take?

A)Give K-Lor as scheduled now.
B)Hold the scheduled dose of Lasix.
C)Assess the patient's pulse rate.
D)Monitor the urine output.

Question 18

A patient is started on bumetanide (Bumex). Which of the following would be most important for the nurse to monitor?

A)Sacral edema
B)Muscle weakness
C)Skin turgor
D)Temperature

Question 19

Which of the following would define preload?

A)Amount of force ventricles exert to open valves and eject blood
B)Degree of muscle stretch in atrium during diastole
C)Degree of stretch in ventricles before systole
D)Ejection of blood from ventricles

Question 20

A patient is receiving potassium (K-Lor) 20 mEq/L, furosemide (Lasix) 20 mg, and digoxin (Lanoxin) 0.125 mg orally. The patient's potassium level is 4 mEq/L. The patient's output for the last 8 hours was 350 mL. The nurse is scheduled to give the medications now. What should the nurse do?

A)Inform the RN.
B)Hold the scheduled dose of Lasix.
C)Hold the scheduled dose of Lanoxin.
D)Give medications as scheduled now.

Question 21

The nurse is providing home care for a patient with chronic heart failure who says, "I don't think I'm going to go to cardiac rehab anymore, it is too hard to get there. Besides, if I'm going to die, I don't want to die on a treadmill." Which of the following responses by the nurse is best?

A)"People don't die on the treadmill, it's to make your heart stronger."
B)"I don't blame you for feeling frustrated, I hate to exercise too."
C)"You sound upset. Did you know research shows that cardiac rehab programs give people better medical outcomes and a higher quality of life?"
D)"It sounds like you want to give up. I'll call the doctor and have you transferred to the hospice program."

Question 22

The nurse is caring for a patient who has chronic heart failure and is scheduled for pacemaker placement. The nurse recognizes additional teaching is required by which of the following patient statements?

A)"The pacemaker will help keep a steady rhythm so blood is pumped more efficiently."
B)"The pacemaker helps treat my heart failure by making my heart pump regularly."
C)"I need to have this surgery to reduce the risk of sudden death."
D)"I won't have to take my cardiac medications after the surgery."

Question 23

In a patient who has had cardiac surgery, chest tube drainage greater than ________________mL/hr may lead to hypovolemia and a decrease in cardiac output.

Question 24

The nurse is contributing to a patient's plan of care who is recovering from heart transplant surgery. The patient is shivering and has weak peripheral pulses, mottled skin on the feet, and excessive chest tube drainage. Which nursing diagnosis would be a priority for the nurse to recommend?

A)Pain related to sternotomy and incisions
B)Decreased Cardiac Output due to hypovolemia
C)Risk for Infection due to inadequate primary defenses from surgical wound and immunosuppression
D)Risk for Impaired Skin/Tissue Integrity due to incision

Question 25

For a patient with chronic obstructive pulmonary disease (COPD) who needs oxygen, the oxygen flow should generally be limited to ____________________/min.

Question 26

The nurse is reinforcing discharge teaching for a patient with a history of right-sided heart failure. Which of the following would be included?

A)"It is important for you to weigh yourself daily and call the doctor if you gain more than 2 pounds in 1 day."
B)"Part of your heart tissue has died, so you will need to get plenty of rest."
C)"You should increase the amount of iron in your diet."
D)"Watch for diarrhea, as it is a symptom of increased failure."

Question 27

In a patient with heart failure, which of the following occur as compensatory mechanisms to help maintain adequate blood flow out of the heart? (Select all that apply.?

A)Epinephrine and norepinephrine are released.
B)Muscle mass of the heart decreases.
C)Kidneys activate the renin-angiotensin-aldosterone system.
D)Urine output increases.
E)Heart muscles stretch to increase the force of myocardial contraction.
F)Oxygen demand of the heart is lowered.Completion
Complete each statement.

Question 28

The nurse is teaching a patient with heart failure how to avoid activity that results in Valsalva's maneuver. Which of these observations by the nurse would indicate that the teaching has been effective?

A)The patient strains while using the commode.
B)The patient uses a straw when drinking.
C)The patient takes shallow breaths.
D)The patient breathes normally when sitting up.Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 29

The nurse is reinforcing teaching to a patient prescribed captopril (Capoten). Which of the following should the nurse specifically include in instructions? (Select all that apply.?

A)Take medication with meals.
B)Check blood pressure weekly and report changes.
C)Report any cough that develops.
D)Report any swelling of the hands, feet, or tongue or difficulty swallowing.
E)Use sunscreen to prevent photosensitivity.
F)Report to the laboratory weekly for laboratory follow-up.

Question 30

The nurse is documenting a patient's report of shortness of breath after lying down, which caused a feeling of suffocation. Which of the following terms would the nurse document?

A)Exertional dyspnea
B)Orthopnea
C)Activity-induced dyspnea
D)Paroxysmal nocturnal dyspnea

Question 31

As part of discharge teaching, the nurse is instructing a patient on the use of digoxin. What should be included in the teaching? (Select all that apply.?

A)Change position quickly to avoid orthostatic hypotension.
B)Take pulse before taking medication and if below 60 or above 100, call the physician.
C)Report blurred vision, photophobia, or seeing yellowish green halos.
D)Take medication exactly as directed at the same time each day.
E)Report if a persistent cough occurs.

Question 32

The nurse reinforced teaching for a patient awaiting a heart transplant. Which of these, if stated by a patient, indicates to the nurse correct understanding of the usual criteria used for a potential heart donor? (Select all that apply.?

A)Age less than 55 years
B)Presence of no active infections
C)Presence of no significant cardiac disease
D)Weight within 35 lb of prospective recipient
E)No hypertension or diabetes
F)Absence of malignant disease

Question 33

The nurse is reinforcing discharge teaching for a patient taking antirejection medication following a heart transplant. Which of the following beverages should the nurse instruct the patient to avoid?

A)Cranberry juice
B)Tomato juice
C)Grapefruit juice
D)Milk