Nokea
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.
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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.
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.
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 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.
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.