Question 1

A nurse is preparing to administer digoxin (Lanoxin) to a patient. The patient's heart rate is 62 beats per minute, and the blood pressure is 120/60 mm Hg. The last serum electrolyte value showed a potassium level of 5.2 mEq/L. What will the nurse do?

Accepted Answer

The patient's serum potassium level is above normal limits, but only slightly. An elevated potassium level can reduce the effects of digoxin, so there is no risk of toxicity. There is no indication that an increased dose of digoxin is needed. There is no indication for a diuretic. The heart rate is acceptable; doses should be withheld if the heart rate is less than 60 beats per minute.

Question 2

A patient with heart failure who has been given digoxin (Lanoxin) daily for a week complains of nausea. Before giving the next dose, the nurse will:

Accepted Answer

Anorexia, nausea, and vomiting are the most common adverse effects of digoxin and should cause nurses to evaluate for more serious signs of toxicity. If the HR is greater than 60 beats per minute, the dose may be given. Nausea by itself is not a sign of toxicity. A decreased dose is not indicated. A serum potassium level less than 3.5 mEq/L is an indication for withholding the dose.

Question 3

A patient has heart failure and is taking an ACE inhibitor. The patient has developed fibrotic changes in the heart and vessels. The nurse expects the provider to order which medication to counter this development?

Accepted Answer

Aldosterone antagonists are added to therapy for patients with worsening symptoms of HF. Aldosterone promotes myocardial remodeling and myocardial fibrosis, so aldosterone antagonists can help with this symptom. ARBs are given for patients who do not tolerate ACE inhibitors. Beta blockers do not prevent fibrotic changes. DRIs are not widely used.

Question 4

The potassium-sparing diuretic spironolactone (Aldactone) prolongs survival and improves heart failure symptoms by which mechanism?

Accepted Answer

Spironolactone prolongs survival in patients with HF primarily by blocking receptors for aldosterone. Spironolactone cause only minimal diuresis. Spironolactone does not reduce afterload, and it does not reduce venous pressure enough to prolong survival, because it causes only minimal diuresis.

Question 5

A patient with moderate heart failure begins taking a thiazide diuretic. The nurse will tell the patient to expect which outcome when taking this drug?

Accepted Answer

Diuretics help reduce fluid volume overload which, by reducing pulmonary edema, can improve exercise tolerance. Diuretics do not improve cardiac output. ACE inhibitors are used to prevent cardiac remodeling and to improve long-term survival.

Question 6

A nurse is discussing heart failure with a group of nursing students. Which statement by a student reflects an understanding of how compensatory mechanisms can compound existing problems in patients with heart failure?

Accepted Answer

The heart rate increases to improve cardiac output, but it may prevent adequate ventricular filling. An increase in arteriole tone improves tissue perfusion but also increases both the resistance to the pumping of the heart and the cardiac workload. Increased contractility helps improve cardiac output but is detrimental because it increases the oxygen demand of the heart. An increase in venous tone improves ventricular filling but, as the ventricles fail, blood can back up and cause pulmonary edema.

Question 7

A patient with Stage C heart failure (HF) who has been taking an ACE inhibitor, a beta blocker, and a diuretic begins to have increased dyspnea, weight gain, and decreased urine output. The provider orders spironolactone (Aldactone). The nurse will make sure that the patient:

Accepted Answer

Spironolactone is added to therapy for patients with worsening symptoms of HF. Because spironolactone is a potassium-sparing diuretic, patients should not take supplemental potassium. Patients taking digoxin need to monitor their heart rate. Extra fluids are not indicated. Salt substitutes contain potassium.

Question 8

Which medications are included in first-line therapy for heart failure? (Select all that apply.)

Accepted Answer

For routine therapy, heart failure is treated with agents that inhibit the RAAS, beta blockers, and diuretics. Aldosterone antagonists and cardiac glycosides are not first-line drugs for HF.

Question 9

A patient is taking a thiazide diuretic for hypertension and quinidine to treat a dysrhythmia. The prescriber orders digoxin 0.125 mg to improve this patient's cardiac output. The nurse should contact the provider to request:

Accepted Answer

Quinidine can cause plasma levels of digoxin to rise; concurrent use of quinidine and digoxin is contraindicated. There is no indication for adding spironolactone unless this patient's potassium level is elevated. The dose of digoxin ordered is a low dose. Potassium supplements are contraindicated with digoxin.

Question 10

A patient with heart failure who has been taking an ACE inhibitor, a thiazide diuretic, and a beta blocker for several months comes to the clinic for evaluation. As part of the ongoing assessment of this patient, the nurse will expect the provider to evaluate:

Accepted Answer

Patients taking thiazide diuretics can develop hypokalemia, which can increase the risk for dysrhythmias; therefore, the serum electrolyte levels should be monitored closely. A complete blood count is not recommended. This patient is taking the drugs recommended for patients with Stage C heart failure; although the patient's quality of life and ability to participate in activities should be monitored, routine measurement of the ejection fraction and maximal exercise capacity is not recommended.

Question 11

A nurse prepares to administer a scheduled dose of digoxin. The nurse finds a new laboratory report showing a plasma digoxin level of 0.7 ng/mL. What action should the nurse take?

Accepted Answer

The optimum plasma digoxin range is 0.5 to 0.8 ng/mL. The patient's pulse should be checked before administration, as always, and the digoxin should be administered. The digoxin does not have to be withheld, nor does the prescriber need to be notified. If the digoxin level is demonstrating a trend of increasing, the issue should be discussed in rounds. Digibind is not indicated, because the digoxin level is therapeutic.

Question 12

A diabetic patient is recovering from a myocardial infarction but does not have symptoms of heart failure. The nurse will expect to teach this patient about:

Accepted Answer

This patient is classified as having Stage B heart failure with no current symptoms but with structural heart disease strongly associated with the development of heart failure. Treatment at this stage includes an ACE inhibitor and a beta blocker to help prevent the progression of symptoms. Biventricular pacemakers are used for patients in Stage C heart failure and have more advanced structural disease and symptoms. Dietary supplements and exercise have not been proven to prevent structural heart disease. Diuretics and digoxin are used for patients with Stage C heart failure.

Question 13

A patient with chronic hypertension is admitted to the hospital. During the admission assessment, the nurse notes a heart rate of 96 beats per minute, a blood pressure of 150/90 mm Hg, bibasilar crackles, 2+ pitting edema of the ankles, and distension of the jugular veins. The nurse will contact the provider to request an order for which medication?

Accepted Answer

This patient shows signs of fluid volume overload and needs a diuretic. Furosemide is a high-ceiling (loop) diuretic, which can produce profound diuresis very quickly even when the glomerular filtration rate (GFR) is low. An ACE inhibitor will not reduce fluid volume overload. Digoxin has a positive inotropic effect on the heart, which may improve renal perfusion, but this is not its primary effect. Spironolactone is a potassium-sparing diuretic with weak diuresis effects; it is used in conjunction with other diuretics to improve electrolyte balance.

Question 14

A man asks a nurse why he cannot use digoxin (Lanoxin) for his heart failure, because both of his parents used it for HF. The nurse will explain that digoxin is not first-line therapy for which reason?

Accepted Answer

Digoxin improves cardiac output, alters electrical effects, and helps to decrease sympathetic outflow from the central nervous system (CNS) through its neurohormonal effects; however, it does not alter the underlying pathology of heart failure or prevent cardiac remodeling. Digoxin causes bradycardia and increases the cardiac workload by increasing contractility. It has a narrow therapeutic range and many adverse effects. Digoxin does not improve life expectancy; in women it may actually shorten life expectancy.

Question 15

A patient has been taking digoxin (Lanoxin) 0.25 mg, and furosemide (Lasix) 40 mg, daily. Upon routine assessment by the nurse, the patient states, "I see yellow halos around the lights." The nurse should perform which action based on this assessment?

Accepted Answer

Yellow halos around lights indicate digoxin toxicity. The use of furosemide increases the risk of hypokalemia, which in turn potentiates digoxin toxicity. The patient should also be assessed for headache, nausea, and vomiting, and blood should be drawn for measurement of the serum digoxin level. The nurse should not withhold the dose of furosemide until further assessment is done, including measurement of a serum digoxin level. No evidence indicates that the patient is in worsening heart failure. Documentation of findings is secondary to further assessment and prevention of digoxin toxicity.

Question 16

An 88-year-old patient with heart failure has progressed to Stage D and is hospitalized for the third time in a month. The nurse will expect to discuss which topic with the patient's family?

Accepted Answer

Patients in Stage D heart failure have advanced structural heart disease. For eligible patients, the best long-term solution is heart transplantation, but this patient probably is not eligible, given his advanced age. End-of-life care should be discussed. Antidysrhythmic medications are not indicated and may make symptoms worse. An implantable mechanical assist device is used in patients awaiting heart transplantation.

Question 17

A patient newly diagnosed with heart failure is admitted to the hospital. The nurse notes a pulse of 90 beats per minute. The nurse will observe this patient closely for:

Accepted Answer

As the heart rate increases, ventricular filling decreases, and cardiac output and renal perfusion decrease. Tachycardia does not elevate blood pressure. Jugular vein distension and shortness of breath occur with fluid volume overload.

Question 18

Which are expected effects of cardiac glycosides? (Select all that apply.)

Accepted Answer

Digoxin slows the heart rate, modulates the activity of neurohormonal systems, and increases the force of contraction. It does not decrease cardiac output or reduce the force of contraction.

Question 19

A patient is taking enalapril (Vasotec). The nurse understands that patients taking this type of drug for heart failure need to be monitored carefully for:

Accepted Answer

One of the principal effects of angiotensin-converting enzyme (ACE) inhibitors is hyperkalemia, which is due to decreased aldosterone release arising from blockage of angiotensin II. There is no indication that careful monitoring of sodium for increased levels is indicated. Vasotec is indicated for heart failure, not hypertension. The drug therapy should be monitored to ascertain its effectiveness, but hyperkalemia is the main concern. Hyperkalemia, not hypokalemia, is a concern because of the decreased aldosterone release that occurs with blockage of angiotensin II.

Question 20

A patient with heart failure who takes a thiazide diuretic and digoxin (Lanoxin) is admitted for shortness of breath. The patient's heart rate is 66 beats per minute, and the blood pressure is 130/88 mm Hg. The serum potassium level is 3.8 mEq/L, and the digoxin level is 0.8 ng/mL. The nurse admitting this patient understands that the patient:

Accepted Answer

This patient has a normal serum potassium level, and the digoxin level is normal. The patient is showing signs of pulmonary edema, which indicates progression of heart failure. The digoxin level is within normal limits, and the heart rate is above 60 beats per minute, so digoxin toxicity is not likely. There is no sign of renal failure. A potassium-sparing diuretic is not indicated.

Quiz 48: Drugs for Heart Failure