Nokea
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).
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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.
The nurse is conducting a health history on a patient with heart failure. Which of the following conditions in the patient's health history is a precipitating cause of heart failure?
- A. Hyperthyroidism
- B. Anemia
- C. Hypovolemia
- D. Diabetes
Correct Answer: B
Rationale: Anemia is a precipitating cause of heart failure. Also, hypovolemia and hypothyroidism are precipitating causes. Diabetes is not a precipitating cause of heart failure.
A patient with heart failure has a new order for lisinopril 10 mg PO. After administering the first dose and teaching the patient about lisinopril, which statement by the patient indicates that teaching has been effective?
- A. I will call for help when I need to get up to use the bathroom.
- B. I will be sure to take the medication after eating something.
- C. I will need to include more high-potassium foods in my diet.
- D. I will expect to feel more short of breath for the next few days.
Correct Answer: A
Rationale: Lisinopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE inhibitors are potassium sparing, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is not an expected effect of ACE inhibitors, which are best absorbed when taken an hour before eating.
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 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.