Question 1

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

Accepted Answer

A decrease in oxygen saturation to less than 92% indicates hypoxemia.The nurse should administer supplemental oxygen immediately to the patient.An increase in apical pulse rate,1-kg weight gain,and decreases in urine output also indicate worsening heart failure and require nursing actions,but the low oxygen saturation rate requires the most immediate nursing action.

Question 2

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 ?

Accepted 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.

Question 3

After receiving change-of-shift report on a heart failure unit,which patient should the nurse assess first?

Accepted Answer

The patient's low potassium level increases the risk for digoxin toxicity and potentially fatal dysrhythmias.The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level.The other patients also have side effects of their medications,but their symptoms do not indicate potentially life-threatening complications.

Question 4

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?

Accepted 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.The other data indicate that the patient's heart failure requires more effective therapies,but they do not require nursing action as rapidly as the low serum potassium level.

Question 5

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)?

Accepted Answer

An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN.Teaching patients,making adjustments to the drip rate for vasoactive medications,and monitoring for serious complications such as extravasation require RN level education and scope of practice.

Question 6

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?

Accepted Answer

The patient's BP indicates that the dose of metoprolol may need to be decreased because of hypotension.Bradycardia is a frequent adverse effect of b-adrenergic blockade,but the rate of 56 is not unusual with â-adrenergic blocker therapy.b-Adrenergic blockade initially will worsen symptoms of heart failure in many patients,and patients should be taught that some increase in symptoms,such as fatigue and edema,is expected during the initiation of therapy with this class of drugs.

Quiz 35: Nursing Management: Heart Failure

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

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 ?

After receiving change-of-shift report on a heart failure unit,which patient should the nurse assess first?

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?

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?