Nokea
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.
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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 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.
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 nurse working in the heart failure clinic will know that teaching for a patient with newly diagnosed heart failure has been effective when the patient does which of the following actions?
- A. Uses an additional pillow to sleep when feeling short of breath at night.
- B. Tells the home care nurse that furosemide is taken daily at bedtime.
- C. Calls the clinic when the weight increases from 56 to 59 kg in 2 days.
- D. Says that the nitroglycerin patch will be used for any chest pain that develops.
Correct Answer: C
Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of more than 2 kg in a 2 day period. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an 'as necessary' basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by elevating the head of the bed further.
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.