Nokea
An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with an ACE inhibitor. Which of these assessment findings is most important for the nurse to report to the health care provider?
- A. Pulse rate of 56
- B. 2+ pedal edema
- C. BP of 88/42 mm Hg
- D. Complaints of fatigue
Correct Answer: C
Rationale: The patient's BP indicates that the dose of the ACE inhibitor may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of β-adrenergic blockade, but the rate of 56 is not unusual with β-blocker therapy. β-adrenergic blockade initially will worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.
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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.
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.
The nurse is providing health-promotion teaching related to heart health and is explaining modifiable and nonmodifiable risk factors. Smoking is a modifiable risk factor. After a diagnosis of cardiovascular-related illness, approximately what percentage of patients that were smokers quit?
- A. 5
- B. 15
- C. 25
- D. 50
Correct Answer: A
Rationale: After diagnosis of a cardiovascular-related illness, fewer than 5% of Canadians quit smoking.
The nurse is caring for an older-adult patient with heart failure and learns that the patient lives alone and sometimes confuses the 'water pill' with the 'heart pill.' When planning for the patient's discharge the nurse will facilitate which of the following actions?
- A. Transfer to a dementia care service
- B. Referral to a home health care agency
- C. Placement in a long-term care facility
- D. Arrangements for around-the-clock care
Correct Answer: B
Rationale: The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term care, or around-the-clock home care.
The nurse is caring for a patient with chronic heart failure. Which of the following conditions is a cause of chronic heart disease?
- A. Dysrhythmias
- B. Pulmonary embolus
- C. Myocarditis
- D. Congenital heart disease
Correct Answer: D
Rationale: Congenital heart disease is a cause of chronic heart failure. Dysrhythmias, pulmonary embolus, and myocarditis are causes of acute heart failure.