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?

Accepted Answer

The client'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 other client problems.

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?

Accepted Answer

Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease client anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it also will increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this client, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

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?

Accepted Answer

Teaching for a client with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of more than 2 kg in a 2 day period. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in clients with heart failure and should be used daily, not on an "as necessary" basis.
Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The client should call the clinic if increased orthopnea develops, rather than just compensating by elevating the head of the bed further.

Question 4

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

Accepted Answer

The client who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other clients also should be assessed as quickly as possible, but do not have indications of severe decreases in tissue perfusion.

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?

Accepted Answer

The data about the client suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the client's home situation and help the client develop a method for taking the two medications as directed. There is no evidence that the client requires services such as dementia care, long-term care, or around-the-clock home 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%?

Accepted Answer

The core measure for the treatment of heart failure in clients with a low ejection fraction is to receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a client with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the client will need to see the primary care provider more frequently than annually.

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?

Accepted Answer

Nitrates cause vasodilation therefore BP should be frequently monitored. Since the client is likely to have orthostatic hypotension, the client should not be encouraged to ambulate. Nitrate does not require titration and the priority is not to teach about safe use at home.

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?

Accepted Answer

Congenital heart disease is a cause of chronic heart failure. Dysrhythmias, pulmonary embolus, and myocarditis are causes of acute heart failure.

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?

Accepted Answer

Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the client is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the client is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

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?

Accepted Answer

Because the client'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 also may indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this client's response.

Question 11

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

Accepted Answer

Women are 36% less likely to enroll in cardiac rehabilitation programs.

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?

Accepted Answer

Anemia is a precipitating cause of heart failure. Also, hypovolemia and hypothyroidism are precipitating causes. Diabetes is not a precipitating cause of heart failure.

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?

Accepted Answer

BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK also may be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

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?

Accepted Answer

Indications for a heart transplant include end-stage heart failure, but other factors such as coping skills, family support, and client motivation to follow the rigorous post-transplant regimen are also considered. Clients with diabetes who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the client's question.

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?

Accepted Answer

The development of dependent edema or a sudden weight gain of more than 2 kg in 2 days is often indicative of exacerbated HF. It is important that the client be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

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?

Accepted Answer

Captopril can cause hypotension, especially after the initial dose, so it is important that the client not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparing, and the nurse should not teach the client to increase sources of dietary potassium. Increased shortness of breath is expected with initiation of ?-blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

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?

Accepted Answer

Milk and yogourt naturally contain a significant amount of sodium, and intake of these should be limited for clients on a diet that limits sodium to 2 g daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2 g sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.

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?

Accepted Answer

This client's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac or respiratory arrest. The other assessments will provide useful data about the client's volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

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?

Accepted Answer

Normal EF is greater than 55% of the ventricular volume. Patients with HF-REF requiring specialist intervention generally have an EF less than or equal to 40%.

Question 20

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

Accepted Answer

In a person with HF, oxygen saturation of the blood may be reduced because the blood is not adequately oxygenated in the lungs. Administration of oxygen, if the O2 saturation is less than 90%, can improve tissue oxygenation. Thus, appropriate use of oxygen therapy helps relieve dyspnea and fatigue. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.

Quiz 37: Nursing Management Heart Failure