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After receiving change-of-shift report, which of the following patients admitted with heart failure should the nurse assess first?
- A. A patient who is receiving IV nitroglycerin and has a blood pressure (BP) of 100/56
- B. A patient who is cool and clammy, with new-onset confusion and restlessness
- C. A patient who had dizziness after receiving the first dose of captopril
- D. A patient who has crackles in both posterior lung bases and is receiving oxygen
Correct Answer: B
Rationale: The patient who has 'wet-cold' clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible, but do not have indications of severe decreases in tissue perfusion.
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During a visit to a patient with chronic heart failure, the home care nurse finds that the patient 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 diagnosis for the patient?
- A. Activity intolerance related to physical deconditioning
- B. Disturbed body image related to alteration in self-perception
- C. Impaired skin integrity related to alteration in fluid volume (peripheral edema)
- D. Ineffective breathing pattern related to respiratory muscle fatigue
Correct Answer: A
Rationale: The patient'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 patient problems.
The nurse is caring for a patient with heart failure with reduced ejection fraction. Which of the following values should the nurse expect to assess in the patient related to ejection fraction?
- A. 40%
- B. 60%
- C. 80%
- D. 90%
Correct Answer: A
Rationale: 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%.
Which assessment finding in a patient admitted with chronic heart failure requires the most rapid action by the nurse?
- A. Oxygen saturation of 88%
- B. Weight gain of 1 kg
- C. Apical pulse rate of 106 beats/minute
- D. Urine output of 50 ml over 2 hours
Correct Answer: A
Rationale: 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.
The nurse is teaching the patient with heart failure about a 2 g sodium diet. Which of the following foods should the nurse explain to the patient that need to be restricted?
- A. Canned and frozen fruits
- B. Fresh or frozen vegetables
- C. Milk, yogurt, and other milk products
- D. Eggs and other high-cholesterol foods
Correct Answer: C
Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients 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.
The nurse is caring for a patient with Class III status (NYHA) heart failure and type 2 diabetes and the patient asks the nurse whether heart transplant is a possible therapy. Which of the following responses by the nurse is best?
- A. Since you have diabetes, you would not be a candidate for a heart transplant.
- B. The choice of a patient for a heart transplant depends on many different factors.
- C. Your heart failure has not reached the stage in which heart transplants are considered.
- D. People who have heart transplants are at risk for multiple complications after surgery.
Correct Answer: B
Rationale: Indications for a heart transplant include end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous post-transplant regimen are also considered. Patients 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 patient's question.