Question 1

The nurse is auscultating the lungs of a patient with heart failure. Which can the nurse expect to document?

Accepted Answer

Crackles are often heard in patients with heart failure due to fluid accumulation in the lungs, which is a common symptom of the condition.

Question 2

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

Accepted Answer

Obtaining a bedside commode addresses the patient's independence and mobility needs while also adhering to the prescribed bedrest, thus minimizing the risk of exacerbating the patient's heart failure condition.

Question 3

The HCP informs the licensed practical nurse/licensed vocational nurse (LPN/LVN) that the patient has stage 3 heart failure. The patient asks what this means. Which explanation by the nurse is most appropriate?

Accepted Answer

Stage 3 heart failure indicates that the patient has heart failure with symptoms that are noticeable during everyday activities, reflecting a more advanced stage of the condition, not just at risk or without symptoms.

Question 4

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.)

Accepted Answer

These criteria ensure the donor heart is healthy and suitable for transplantation: no hypertension or diabetes, absence of malignant disease, no active infections, and no significant cardiac disease.

Question 5

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?

Accepted Answer

The answer of A patient with heart failure has clavicle...

Question 6

The nurse is teaching a patient who is receiving information about food choices high in potassium. Which food choice made by the patient indicates an understanding of the teaching? 1.1 cup of spaghetti noodles

Accepted Answer

A large baked potato is high in potassium, making it a good choice for someone looking to increase their potassium intake. The other options listed contain much lower amounts of potassium.

Question 7

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?

Accepted Answer

The best response by the nurse is to acknowledge the patient's feelings and provide information about the benefits of cardiac rehabilitation. This approach is supportive and informative, helping to alleviate fears by highlighting the positive outcomes associated with continuing the program.

Question 8

The nurse is assessing a patient who underwent cardiac surgery. Which finding warrants a phone call to the HCP?

Accepted Answer

The presence of yellow-green sputum can indicate an infection, which is a significant concern post-surgery and warrants immediate communication with a healthcare provider (HCP).

Question 9

The nurse is caring for a patient and notes the patient is coughing up pink, frothy sputum. Which action should the nurse take?

Accepted Answer

Coughing up pink, frothy sputum is a sign of pulmonary edema, a condition that requires immediate medical attention. Notifying the health care provider is the appropriate action to ensure the patient receives the necessary care.

Question 10

The nurse is reviewing orders for a patient and notes the patient is prescribed valsartan/sacubitril (Entresto). Which medication in the patient's medication history would lead the nurse to seek clarification before administering the Entresto?

Accepted Answer

Entresto (valsartan/sacubitril) should not be administered with ACE inhibitors like enalapril (Vasotec) due to the increased risk of angioedema. A washout period of 36 hours between the use of an ACE inhibitor and Entresto is recommended.

Question 11

A patient with a potassium level of 3.0 mEq/L is to receive furosemide (Lasix) 20 mg by mouth. What action should the nurse take?

Accepted Answer

Furosemide (Lasix) is a potent diuretic that can further lower potassium levels. A potassium level of 3.0 mEq/L is already low, so administering Lasix could exacerbate hypokalemia. Consulting with an RN or a healthcare provider is appropriate to assess the need for potassium supplementation or modification of the medication order.

Question 12

The nurse is caring for a group of patients. Which patient should the nurse see first?

Accepted Answer

A sudden onset of confusion can indicate a serious and potentially life-threatening condition such as stroke, infection, or metabolic imbalance, and requires immediate assessment and intervention.

Question 13

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

Accepted Answer

Anorexia is a common symptom of digoxin toxicity, along with nausea, vomiting, and visual disturbances, and should be reported for follow-up.

Question 14

The nurse is caring for a patient with pulmonary edema. The nurse should place the patient in which position?

Accepted Answer

Fowler's position (sitting or semi-sitting position) helps to improve breathing and oxygenation by reducing the pressure on the diaphragm from abdominal organs, which is beneficial for patients with pulmonary edema.

Question 15

The nurse is reinforcing teaching for a patient being discharged home on captopril (Capoten). Which statement made by the patient indicates an understanding of the teaching?

Accepted Answer

The answer of The nurse is reinforcing teaching for a...

Question 16

As part of discharge teaching, the nurse is instructing a patient on the use of digoxin (Lanoxin). What should be included in the teaching? (Select all that apply.)

Accepted Answer

Digoxin is a medication used to treat heart conditions. Patients should be instructed to take it exactly as directed at the same time each day (C) to maintain consistent blood levels. They should report any visual disturbances such as blurred vision, photophobia, or seeing yellowish green halos (D), as these can be signs of digoxin toxicity. It's also important to monitor heart rate before taking the medication; if the pulse is below 60 or above 100, the physician should be contacted (E), as this could indicate an adverse reaction or the need for dose adjustment. Reporting a persistent cough (A) is more associated with ACE inhibitors, and changing position quickly to avoid orthostatic hypotension (B) is not specifically related to digoxin use.

Question 17

The nurse is reviewing laboratory results for a newly admitted patient. Which result should be of most concern to the nurse?

Accepted Answer

A B-type natriuretic peptide (BNP) level of 900 pg/mL is significantly elevated and indicates heart failure, which should be of most concern to the nurse.

Question 18

The nurse is teaching a patient about prevention of paroxysmal nocturnal dyspnea. Which topic should the nurse include in the teaching?

Accepted Answer

Sleeping upright on three pillows can help prevent paroxysmal nocturnal dyspnea by reducing the return of blood to the heart and lungs while lying down, which can decrease the risk of pulmonary congestion and dyspnea during sleep.

Question 19

The nurse is caring for a group of patients. Which patient is at highest risk for developing heart failure?

Accepted Answer

African Americans have a higher prevalence of hypertension, which is a significant risk factor for heart failure.

Question 20

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, and coarse crackles in lower lung bases. What action should the nurse take?

Accepted Answer

The patient's symptoms and vital signs suggest acute exacerbation of heart failure, possibly with pulmonary edema (indicated by coarse crackles in the lower lung bases), which is a medical emergency. Consulting the registered nurse (RN) is the appropriate action to ensure prompt evaluation and management.

Quiz 26: Nursing Care of Patients With Heart Failure