Deck 26: Nursing Care of Patients With Heart Failure

Question 1

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

Answer 1

Excess Fluid Volume

Question 2

A patient with increased dyspnea has bilateral crackles on auscultation.Which action should the nurse take?

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

Answer 2

Raise the head of the bed to 90 degrees.

Question 3

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

Answer 3

Give the scheduled Bumex.

Question 4

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

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

Question 5

A patient with a potassium level of 3 mEq/L is to receive furosemide (Lasix)20 mg by mouth.What action should the nurse take?

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

Question 6

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

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

Question 7

A patient is receiving digoxin (Lanoxin)daily.Which symptom should the nurse report for follow-up related to the digoxin?

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

Question 8

A patient has been given bumetanide (Bumex)3 mg intravenously.Which action should the nurse take after this medication is administered?

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

Question 9

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

A) Bradycardia
B) Constipation
C) Skin flushing
D) Muscle cramps

Question 10

The nurse is collecting data from a patient who is in left-sided heart failure.Which finding should the nurse identify as being consistent with this diagnosis?

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

Question 11

A patient with heart failure has clavicle muscle retractions,nostril flaring,and labored breathing.Vital signs are: blood pressure 162/84 mm Hg,pulse 120 beats/min,and respirations 32/min.Which patient data requires immediate action?

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

Question 12

The nurse provides morphine as prescribed to a patient experiencing anxiety,dyspnea,diaphoresis; retractions; pink,frothy sputum; blood pressure 174/86 mm Hg; pulse 116 beats/min; and respirations 32/min.Which finding should the nurse consider as desirable after receiving the morphine?

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

Question 13

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 and the dose of K-Lor 10 mEq/L is scheduled to be given now.What action should the nurse take?

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

Question 14

The nurse is caring for a patient who is prescribed furosemide (Lasix).Which laboratory result should the nurse review first?

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

Question 15

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 and urine output for the last 8 hours was 350 mL.What should the nurse do about the prescribed medications?

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

Question 16

A patient with heart failure is prescribed bedrest however becomes angry and walks to the bathroom independently to use the commode.How should the nurse handle this situation?

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

Question 17

A patient is taking bumetanide (Bumex).What is the most important for the nurse to monitor in this patient?

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

Question 18

During a visit to the home of a patient with heart failure and diabetes the nurse learns that the patient "feels strange." Data collected includes 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) Consult the RN.
B) Give the patient orange juice.
C) Assist patient to bed for a nap.
D) Recheck vital signs in 30 minutes.

Question 19

A patient is diagnosed with a heart problem that affects preload.How should the nurse describe preload to the patient?

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

Question 20

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 and the dose of K-Lor 10 mEq/L is scheduled to be given now.What action should the nurse take?

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

Question 21

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

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

Question 22

The nurse is monitoring the chest tube drainage for a patient recovering from cardiac surgery.What volume should the nurse report to the charge nurse?

A) 50 mL/hr
B) 100 mL/hr
C) 150 mL/hr
D) 225 mL/hr

Question 23

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

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

Question 24

A patient diagnosed with complete right-sided heart failure.For which additional health problem should the nurse collect data on this patient?

A) Dissecting aorta
B) Cor pulmonale
C) Carotid artery stenosis
D) Abdominal aortic aneurysm

Question 25

The nurse reinforced teaching for a patient awaiting a heart transplant.Which statements indicate that the patient understands the usual criteria used for a potential heart donor? (Select all that apply.)

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

Question 26

A patient recovering from heart transplant surgery is shivering,has weak peripheral pulses,mottled skin on the feet,and excessive chest tube drainage.Which nursing diagnosis should the nurse recommend?

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

Question 27

While collecting data,the nurse suspects that a patient is demonstrating signs of heart failure.What findings did the nurse use to come to this conclusion? (Select all that apply.)

A) Hunger
B) Fatigue
C) Dry cough
D) Ankle edema
E) Shortness of breath when lying down

Question 28

A patient with heart failure is prescribed an angiotensin-converting enzyme inhibitor (ACEI).What should the nurse teach the patient about this medication? (Select all that apply.)

A) Prevents remodeling
B) Reduces fluid volume
C) Lowers blood pressure
D) Reduces workload on the heart
E) Decrease pulmonary venous pressure

Question 29

The health care provider (HCP)wants to be notified if a patient recovering from a heart transplant has a urine output less than 0.5 mL/kg/hour.The patient weighs 176 lbs.What is the amount of urine the patient has to produce before the HCP is notified?

Question 30

The nurse is teaching a patient with heart failure how to avoid activity that results in Valsalva's maneuver.Which observation indicates that teaching has been effective?

A) The patient takes shallow breaths.
B) The patient uses a straw when drinking.
C) The patient strains while using the commode.
D) The patient breathes normally when sitting up.

Question 31

The nurse is reinforcing teaching provided to a patient with chronic heart failure who is scheduled for pacemaker placement.Which patient statement indicates that additional instruction is required?

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

Question 32

A patient requiring oxygen therapy is being discharged home.At which flow rate should the nurse instruct the patient to keep the oxygen level?

A) 1 liter
B) 2 to 6 liters
C) 8 liters
D) 10 liters

Question 33

The nurse is reinforcing discharge teaching provided to a patient with a history of right-sided heart failure.What should the nurse include?

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

Question 34

A patient with lower extremity edema from heart failure is fatigued from constant sleep interruption to void.What should the nurse instruct the patient to promote uninterrupted rest?

A) Take prescribed diuretics immediately before going to bed
B) Recline with the legs below heart level for 1 hour before going to bed
C) Sit with the legs crossed at the ankles for 1 to 2 hours before going to bed
D) Recline with the legs above heart level for 30 minutes before going to bed

Question 35

During a home visit,the nurse learns that a patient with chronic heart failure is planning to quit cardiac rehabilitation because of the fear of dying while on the treadmill.Which response by the nurse is best?

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

Question 36

The nurse is reviewing compensatory mechanisms with a patient in heart failure.What should the nurse include when providing this teraching? (Select all that apply.)

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

Question 37

A patient reports shortness of breath after lying down,which caused a feeling of suffocation.How should the nurse document this finding?

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

Question 38

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