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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.
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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.
Which of the following actions is priority when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving a nitrate?
- A. Monitor blood pressure frequently.
- B. Encourage patient to ambulate in room.
- C. Titrate nitrate rate slowly before discontinuing.
- D. Teach patient about safe home use of the medication.
Correct Answer: A
Rationale: Nitrates cause vasodilation therefore BP should be frequently monitored. Since the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nitrate does not require titration and the priority is not to teach about safe use at home.
Following an acute myocardial infarction, a previously healthy patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about which of the following medications?
- A. Angiotensin-converting enzyme (ACE) inhibitors
- B. Digitalis preparations
- C. β-Adrenergic agonists
- D. Calcium channel blockers
Correct Answer: A
Rationale: ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure. Calcium channel blockers are not generally used in the treatment of heart failure. The β-adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure.
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.
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.