Nokea
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%.
You may also like to solve these questions
Which of the following diagnostic tests will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?
- A. Serum creatine kinase (CK)
- B. Arterial blood gases (ABGs)
- C. B-type natriuretic peptide (BNP)
- D. 12-lead electrocardiogram (ECG)
Correct Answer: C
Rationale: BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK also may be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.
The nurse is caring for a patient in the intensive care unit with acute decompensated heart failure (ADHF) who has symptoms of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been prescribed for the patient. Which of the following actions should the nurse implement first?
- A. Give IV diazepam 2.5 mg
- B. Administer IV morphine sulphate 2 mg
- C. Increase nitroglycerin infusion by 5 mcg/min.
- D. Increase dopamine infusion by 2 mcg/kg/min.
Correct Answer: B
Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it also will increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.
A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which of the following actions should the nurse take first?
- A. Palpate the abdomen.
- B. Assess the orientation.
- C. Check the capillary refill.
- D. Auscultate the lung sounds.
Correct Answer: D
Rationale: This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac or respiratory arrest. The other assessments will provide useful data about the patient's volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.
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.
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.