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A patient 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
Correct Answer: D
Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient 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 patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.
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The nurse is caring for a patient who is receiving IV furosemide and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the patient 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 patient complaints of chest pain
- D. Decreased dyspnea with the head of bed at 30 degrees
Correct Answer: D
Rationale: Because the patient'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 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 patient's response.
The nurse working in the heart failure clinic will know that teaching for a patient with newly diagnosed heart failure has been effective when the patient 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.
Correct Answer: C
Rationale: Teaching for a patient 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 patients 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 patient should call the clinic if increased orthopnea develops, rather than just compensating by elevating the head of the bed further.
A patient with heart failure has a new order for lisinopril 10 mg PO. After administering the first dose and teaching the patient about lisinopril, which statement by the patient 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.
Correct Answer: A
Rationale: Lisinopril can cause hypotension, especially after the initial dose, so it is important that the patient 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 patient to increase sources of dietary potassium. Increased shortness of breath is not an expected effect of ACE inhibitors, which are best absorbed when taken an hour before eating.
The home health nurse is visiting a patient 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 should the nurse do first?
- A. Ask the patient to recall the dietary intake for the last 3 days.
- B. Question the patient about the use of the prescribed medications.
- C. Assess the patient for clinical manifestations of acute heart failure.
- D. Teach the patient about the importance of dietary sodium restrictions.
Correct Answer: C
Rationale: 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 patient 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.
Which topic will the nurse plan to include in discharge teaching for a patient 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
Correct Answer: D
Rationale: The core measure for the treatment of heart failure in patients 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 patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.