Nokea
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.
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A patient who has chronic heart failure tells the nurse, 'I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!' Which of the following information should the nurse document related to this assessment?
- A. Pulsus alternans
- B. Two-pillow orthopnea
- C. Acute bilateral pleural effusion
- D. Paroxysmal nocturnal dyspnea
Correct Answer: D
Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.
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.
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.
Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 38%?
- A. Need to participate in an aerobic exercise program several times weekly
- B. Use of salt substitutes to replace table salt when cooking and at the table
- C. Importance of making a yearly appointment with the primary care provider
- D. Benefits and adverse effects of angiotensin-converting enzyme (ACE) inhibitors
Correct Answer: D
Rationale: The core measure for the treatment of heart failure in patients with a low ejection fraction is to receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.
The nurse is caring for a patient with Class III status (NYHA) heart failure and type 2 diabetes and the patient asks the nurse whether heart transplant is a possible therapy. Which of the following responses by the nurse is best?
- A. Since you have diabetes, you would not be a candidate for a heart transplant.
- B. The choice of a patient for a heart transplant depends on many different factors.
- C. Your heart failure has not reached the stage in which heart transplants are considered.
- D. People who have heart transplants are at risk for multiple complications after surgery.
Correct Answer: B
Rationale: Indications for a heart transplant include end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous post-transplant regimen are also considered. Patients with diabetes who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patient's question.