Chapter 34: Heart
FailureLewis: Medical-
Surgical Nursing, 11th
Edition
, 1. While assessing a 68-yr-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. - CORRECT ANSWERS-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.
2. 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 lb 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 - CORRECT ANSWERS-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 may also indicate that diuresis or improvement in cardiac output has occurred but
are not as specific to evaluating this patient's response.
3. Which topic will the nurse plan to include in discharge teaching for a patient with
heart failure with reduced ejection fraction (HFrEF)?
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. Importance of making an annual appointment with the health care provider
d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors -
CORRECT ANSWERS-ANS: D
The core measures for the treatment of heart failure established by The Joint
Commission indicate that patients with an ejection fraction below 40% should 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.
4. IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. During
the first hours of administration, the nurse will need to titrate the nitroprusside rate down
if the patient develops
a. ventricular ectopy.
b. a dry, hacking cough.
c. a systolic BP below 90 mm Hg.
FailureLewis: Medical-
Surgical Nursing, 11th
Edition
, 1. While assessing a 68-yr-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. - CORRECT ANSWERS-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.
2. 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 lb 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 - CORRECT ANSWERS-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 may also indicate that diuresis or improvement in cardiac output has occurred but
are not as specific to evaluating this patient's response.
3. Which topic will the nurse plan to include in discharge teaching for a patient with
heart failure with reduced ejection fraction (HFrEF)?
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. Importance of making an annual appointment with the health care provider
d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors -
CORRECT ANSWERS-ANS: D
The core measures for the treatment of heart failure established by The Joint
Commission indicate that patients with an ejection fraction below 40% should 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.
4. IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. During
the first hours of administration, the nurse will need to titrate the nitroprusside rate down
if the patient develops
a. ventricular ectopy.
b. a dry, hacking cough.
c. a systolic BP below 90 mm Hg.
