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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.
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The home health nurse is visiting a patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a low-sodium diet and tells the nurse about a 2.3 kg weight gain in the last 3 days. Which of the following actions should the nurse do first?
- A. Ask the patient to recall the dietary intake for the last 3 days.
- B. Question the patient about the use of the prescribed medications.
- C. Assess the patient for clinical manifestations of acute heart failure.
- D. Teach the patient about the importance of dietary sodium restrictions.
Correct Answer: C
Rationale: The development of dependent edema or a sudden weight gain of more than 2 kg in 2 days is often indicative of exacerbated HF. It is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.
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.
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.
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 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.