Deck 37: Nursing Management Heart Failure

Question 1

During a visit to a client with chronic heart failure, the home care nurse finds that the client has ankle edema, a 2 kg weight gain, and complains of "feeling too tired to do anything." Based on these data, which of the following is the best nursing diagnosisfor the client?

A)Activity intolerance related to physical deconditioning
B)Disturbed body image related to alteration in self-perception
C)Impaired skin integrity related to alteration in fluid volume (peripheral edema)
D)Ineffective breathing pattern related to respiratory muscle fatigue

Answer 1

Activity intolerance related to physical deconditioning

Question 2

The nurse is caring for a client in the intensive care unit with acute decompensated heart failure (ADHF) who has symptoms of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been prescribed for the client. Which ofthe following actions should the nurse implement first?

A)Give IV diazepam 2.5 mg.
B)Administer IV morphine sulphate 2 mg.
C)Increase nitroglycerin infusion by 5 mcg/min.
D)Increase dopamine infusion by 2 mcg/kg/min.

Answer 2

Administer IV morphine sulphate 2 mg.

Question 3

The nurse working in the heart failure clinic will know that teaching for a client with newly diagnosed heart failure has been effective when the client does which of the following actions?

A)Uses an additional pillow to sleep when feeling short of breath at night.
B)Tells the home care nurse that furosemide is taken daily at bedtime.
C)Calls the clinic when the weight increases from 56 to 59 kg in 2 days.
D)Says that the nitroglycerin patch will be used for any chest pain that develops.

Answer 3

Calls the clinic when the weight increases from 56 to 59 kg in 2 days.

Question 4

After receiving change-of-shift report, which of the following clients admitted with heart failure should the nurse assess first?

A)A client who is receiving IV nitroprusside and has a blood pressure (BP) of 100/56
B)A client who is cool and clammy, with new-onset confusion and restlessness
C)A client who had dizziness after receiving the first dose of captopril
D)A client who has crackles in both posterior lung bases and is receiving oxygen

Question 5

The nurse is caring for an older-adult client with heart failure and learns that the client lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the client's discharge the nurse will facilitate which of the followingactions?

A)Transfer to a dementia care service
B)Referral to a home health care agency
C)Placement in a long-term care facility
D)Arrangements for around-the-clock care

Question 6

Which topic will the nurse plan to include in discharge teaching for a client with systolic heart failure and an ejection fraction of 38%?

A)Need to participate in 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 a yearly appointment with the primary care provider
D)Benefits and adverse effects of angiotensin-converting enzyme (ACE) inhibitors

Question 7

Which of the following actions is priority when caring for a client admitted with acute decompensated heart failure (ADHF) who is receiving a nitrate?

A)Monitor blood pressure frequently.
B)Encourage client to ambulate in room.
C)Titrate nitrate rate slowly before discontinuing.
D)Teach client about safe home use of the medication.

Question 8

The nurse is caring for a client with chronic heart failure. Which of the following conditions is a cause of chronic heart disease?

A)Dysrhythmias
B)Pulmonary embolus
C)Myocarditis
D)Congenital heart disease

Question 9

Aclient who has chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" Which of the following information should the nurse document related to this assessment?

A)Pulsus alternans
B)Two-pillow orthopnea
C)Acute bilateral pleural effusion
D)Paroxysmal nocturnal dyspnea

Question 10

The nurse is caring for a client who is receiving IV furosemide and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the client response to the medications, which of the following is the best indicator that the treatment has been effective?

A)Weight loss of 1 kg overnight
B)Hourly urine output greater than 60 mL
C)Reduction in client complaints of chest pain
D)Decreased dyspnea with the head of bed at 30 degrees

Question 11

Which of the following clients is less likely to enroll in a cardiac rehabilitation program?

A)A 64-year-old male who has diabetes
B)A 51-year-old male who has a same-sex partner
C)A 52-year-old single female
D)A 39-year-old male with two children

Question 12

The nurse is conducting a health history on a client with heart failure. Which of the following conditions in the client's health history is a precipitating cause of heart failure?

A)Hyperthyroidism
B)Anemia
C)Hypovolemia
D)Diabetes

Question 13

Which of the following diagnostic tests will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?

A)Serum creatine kinase (CK)
B)Arterial blood gases (ABGs)
C)B-type natriuretic peptide (BNP)
D)12-lead electrocardiogram (ECG)

Question 14

The nurse is caring for a client with Class III status (NYHA) heart failure and type 2 diabetes and the client asks the nurse whether heart transplant is a possible therapy. Which of the following responses by the nurse is best?

A)"Since you have diabetes, you would not be a candidate for a heart transplant."
B)"The choice of a client for a heart transplant depends on many different factors."
C)"Your heart failure has not reached the stage in which heart transplants are considered."
D)"People who have heart transplants are at risk for multiple complications after surgery."

Question 15

The home health nurse is visiting a client with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a low-sodium diet and tells the nurse about a 2.3 kg weight gain in the last 3 days. Which of the following actions shouldthenurse do first?

A)Ask the client to recall the dietary intake for the last 3 days.
B)Question the client about the use of the prescribed medications.
C)Assess the client for clinical manifestations of acute heart failure.
D)Teach the client about the importance of dietary sodium restrictions.

Question 16

A client with heart failure has a new order for captopril 12.5 mg PO. After administering the first dose and teaching the client about captopril, which statement by the client indicates that teaching has been effective?

A)"I will call for help when I need to get up to use the bathroom."
B)"I will be sure to take the medication after eating something."
C)"I will need to include more high-potassium foods in my diet."
D)"I will expect to feel more short of breath for the next few days."

Question 17

The nurse is teaching the client with heart failure about a 2 g sodium diet. Which of the following foods should the nurse explain to the client that need to be restricted?

A)Canned and frozen fruits
B)Fresh or frozen vegetables
C)Milk, yogourt, and other milk products.
D)Eggs and other high-cholesterol foods.

Question 18

A client with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which of the following actions should the nurse take first?

A)Palpate the abdomen.
B)Assess the orientation.
C)Check the capillary refill.
D)Auscultate the lung sounds.

Question 19

The nurse is caring for a client with heart failure with reduced ejection fraction. Which of the following laboratory values should the nurse expect to assess in the client related to ejection fraction?

A)40%
B) 60%
C)80%
D) 90%

Question 20

Which assessment finding in a client admitted with chronic heart failure requires the most rapid action by the nurse?

A)Oxygen saturation of 88%
B)Weight gain of 1 kg
C)Apical pulse rate of 106 beats/minute
D)Urine output of 50 mL over 2 hours

Question 21

An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with an ACE inhibitor. Which of these assessment findings is most important for the nurse to report to the health care provider?

A)Pulse rate of 56
B)2+ pedal edema
C)BP of 88/42 mm Hg
D)Complaints of fatigue

Question 22

The nurse is caring for a client with right-sided heart failure who asks the nurse what caused the heart failure. Which of the following causes is the primary cause of right-sided heart failure?

A)Cor pulmonale
B)Chronic pulmonary hypertension
C)Left-sided heart failure
D)Acute decompensated heart failure

Question 23

The nurse is providing health-promotion teaching related to heart health and is explaining modifiable and nonmodifiable risk factors. Smoking is a modifiable risk factor. After a diagnosis of cardiovascular-related illness, approximately what percentageofclients that were smokers quit?

A)5
B)15
C)25
D)50