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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.
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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 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 a patient with right-sided heart failure who asks the nurse what caused the heart failure. Which of the following causes is the primary cause of right-sided heart failure?
- A. Cor pulmonale
- B. Chronic pulmonary hypertension
- C. Left-sided heart failure
- D. Acute decompensated heart failure
Correct Answer: C
Rationale: The primary cause of right-sided failure is left-sided failure. In this situation, left-sided failure results in pulmonary congestion and increased pressure in the blood vessels of the lungs (pulmonary hypertension).
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.
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.