Level 4 - Exam 1: Heart Failure Questions and
Verified Answers.
While assessing a 68-year-old with ascites, the nurse also notes jugular venous
distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse
knows this finding indicates
a. decreased fluid volume.
b. jugular vein atherosclerosis.
c. increased right atrial pressure.
d. incompetent jugular vein valves. - ANS ANS: C
The jugular veins empty into the superior vena cava and then into the right atrium, so
JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure.
JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid
volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine
for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea.
Which clinical finding is the best indicator that the treatment has been effective?
a. Weight loss of 2 pounds in 24 hours
b. Hourly urine output greater than 60 mL
c. Reduction in patient complaints of chest pain
d. Reduced dyspnea with the head of bed at 30 degrees - ANS ANS: D
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 the 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.
Which topic will the nurse plan to include in discharge teaching for a patient with systolic
heart failure and an ejection fraction of 33%?
a. Need to begin an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
d. Importance of making an annual appointment with the primary care provider - ANS
ANS: C
The core measures for the treatment of heart failure established by The Joint
Commission indicate that patients with an ejection fraction (EF) <40% 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.
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema.
During the first hours of administration, the nurse will need to titrate the nitroprusside
rate if the patient develops
,a. ventricular ectopy.
b. a dry, hacking cough.
c. a systolic BP <90 mm Hg.
d. a heart rate <50 beats/minute. - ANS ANS: C
Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe
hypotension. Coughing and bradycardia are not adverse effects of this medication.
Nitroprusside does not cause increased ventricular ectopy.
A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed,
but I woke up in the middle of the night feeling like I was suffocating!" The nurse will
document this assessment finding as
a. orthopnea.
b. pulses alternant.
c. paroxysmal nocturnal dyspnea.
d. acute bilateral pleural effusion. - ANS ANS: C
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. Pulses alternant 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.
During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that
the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of
"feeling too tired to get out of bed." Based on these data, the best nursing diagnosis for
the patient is
a. activity intolerance related to fatigue.
b. disturbed body image related to weight gain.
c. impaired skin integrity related to ankle edema.
d. impaired gas exchange related to dyspnea on exertion. - ANS ANS: A
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 working on the heart failure unit knows that teaching an older female patient
with newly diagnosed heart failure is effective when the patient states that
a. she will take furosemide (Lasix) every day at bedtime.
b. the nitroglycerin patch is applied when any chest pain develops.
c. she will call the clinic if her weight goes from 124 to 128 pounds in a week.
d. an additional pillow can help her sleep if she is feeling short of breath at night. - ANS
ANS: C
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 3 pounds in 2 days or 3 to
5 pounds in a week. 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
needed" basis. Diuretics should be taken earlier in the day to avoid nocturnal and sleep
, disturbance. The patient should call the clinic if increased orthopnea develops, rather
than just compensating by further elevating the head of the bed.
When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium
diet, the nurse explains that foods to be restricted include
a. canned and frozen fruits.
b. fresh or frozen vegetables.
c. eggs and other high-protein foods.
d. milk, yogurt, and other milk products. - ANS ANS: D
Milk and yogurt naturally contain a significant amount of sodium, and intake of these
should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk
products, such as processed cheeses, have very high levels of sodium and are not
appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of
sodium and can be eaten without restriction.
The nurse plans discharge teaching for a patient with chronic heart failure who has
prescriptions for digoxin (Lanolin) and hydrochlorothiazide (HydroDIURIL). Appropriate
instructions for the patient include
a. limit dietary sources of potassium.
b. takes the hydrochlorothiazide before bedtime.
c. notifies the health care provider if nausea develops.
d. skips the digoxin if the pulse is below 60 beats/minute. - ANS ANS: C
Nausea is an indication of digoxin toxicity and should be reported so that the provider
can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient
will need to include potassium-containing foods in the diet to avoid hypokalemia.
Patients should be taught to check their pulse daily before taking the digoxin and if the
pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be
taken early in the day to avoid sleep disruption.
While admitting an 82-year-old with acute decompensated heart failure to the hospital,
the nurse 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 a
a. consult with a psychologist.
b. transfer to a long-term care facility.
c. referral to a home health care agency.
d. arrangements for around-the-clock care. - ANS ANS: C
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 a psychologist
consult, long-term care, or around-the-clock home care.
Following an acute myocardial infarction, a previously healthy 63-year-old develops
clinical manifestations of heart failure. The nurse anticipates discharge teaching will
include information about
a. digitalis preparations.
Verified Answers.
While assessing a 68-year-old with ascites, the nurse also notes jugular venous
distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse
knows this finding indicates
a. decreased fluid volume.
b. jugular vein atherosclerosis.
c. increased right atrial pressure.
d. incompetent jugular vein valves. - ANS ANS: C
The jugular veins empty into the superior vena cava and then into the right atrium, so
JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure.
JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid
volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine
for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea.
Which clinical finding is the best indicator that the treatment has been effective?
a. Weight loss of 2 pounds in 24 hours
b. Hourly urine output greater than 60 mL
c. Reduction in patient complaints of chest pain
d. Reduced dyspnea with the head of bed at 30 degrees - ANS ANS: D
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 the 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.
Which topic will the nurse plan to include in discharge teaching for a patient with systolic
heart failure and an ejection fraction of 33%?
a. Need to begin an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
d. Importance of making an annual appointment with the primary care provider - ANS
ANS: C
The core measures for the treatment of heart failure established by The Joint
Commission indicate that patients with an ejection fraction (EF) <40% 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.
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema.
During the first hours of administration, the nurse will need to titrate the nitroprusside
rate if the patient develops
,a. ventricular ectopy.
b. a dry, hacking cough.
c. a systolic BP <90 mm Hg.
d. a heart rate <50 beats/minute. - ANS ANS: C
Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe
hypotension. Coughing and bradycardia are not adverse effects of this medication.
Nitroprusside does not cause increased ventricular ectopy.
A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed,
but I woke up in the middle of the night feeling like I was suffocating!" The nurse will
document this assessment finding as
a. orthopnea.
b. pulses alternant.
c. paroxysmal nocturnal dyspnea.
d. acute bilateral pleural effusion. - ANS ANS: C
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. Pulses alternant 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.
During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that
the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of
"feeling too tired to get out of bed." Based on these data, the best nursing diagnosis for
the patient is
a. activity intolerance related to fatigue.
b. disturbed body image related to weight gain.
c. impaired skin integrity related to ankle edema.
d. impaired gas exchange related to dyspnea on exertion. - ANS ANS: A
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 working on the heart failure unit knows that teaching an older female patient
with newly diagnosed heart failure is effective when the patient states that
a. she will take furosemide (Lasix) every day at bedtime.
b. the nitroglycerin patch is applied when any chest pain develops.
c. she will call the clinic if her weight goes from 124 to 128 pounds in a week.
d. an additional pillow can help her sleep if she is feeling short of breath at night. - ANS
ANS: C
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 3 pounds in 2 days or 3 to
5 pounds in a week. 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
needed" basis. Diuretics should be taken earlier in the day to avoid nocturnal and sleep
, disturbance. The patient should call the clinic if increased orthopnea develops, rather
than just compensating by further elevating the head of the bed.
When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium
diet, the nurse explains that foods to be restricted include
a. canned and frozen fruits.
b. fresh or frozen vegetables.
c. eggs and other high-protein foods.
d. milk, yogurt, and other milk products. - ANS ANS: D
Milk and yogurt naturally contain a significant amount of sodium, and intake of these
should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk
products, such as processed cheeses, have very high levels of sodium and are not
appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of
sodium and can be eaten without restriction.
The nurse plans discharge teaching for a patient with chronic heart failure who has
prescriptions for digoxin (Lanolin) and hydrochlorothiazide (HydroDIURIL). Appropriate
instructions for the patient include
a. limit dietary sources of potassium.
b. takes the hydrochlorothiazide before bedtime.
c. notifies the health care provider if nausea develops.
d. skips the digoxin if the pulse is below 60 beats/minute. - ANS ANS: C
Nausea is an indication of digoxin toxicity and should be reported so that the provider
can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient
will need to include potassium-containing foods in the diet to avoid hypokalemia.
Patients should be taught to check their pulse daily before taking the digoxin and if the
pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be
taken early in the day to avoid sleep disruption.
While admitting an 82-year-old with acute decompensated heart failure to the hospital,
the nurse 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 a
a. consult with a psychologist.
b. transfer to a long-term care facility.
c. referral to a home health care agency.
d. arrangements for around-the-clock care. - ANS ANS: C
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 a psychologist
consult, long-term care, or around-the-clock home care.
Following an acute myocardial infarction, a previously healthy 63-year-old develops
clinical manifestations of heart failure. The nurse anticipates discharge teaching will
include information about
a. digitalis preparations.
