A patient with a history of acute decompensated heart failure (ADHF) reports blood-tinged sputum, productive frothy cough, and rapid heart rate. The nurse suspects that which condition induced these clinical manifestations? Show A. Cerebral edema ANS: Pulmonary edema ADHF can manifest as pulmonary edema, which is an acute life-threatening condition. In this condition, the alveoli become filled with serosanguinous fluid, and the clinical manifestations include cough, blood-stained sputum, and rapid heart rate. Cerebral edema presents in the form of seizures, headache, and other neurologic symptoms. Peripheral edema presents as a swelling in the lower extremities. Lymphatic edema presents as hyperplasia and hyperkeratosis. The nurse educates a patient with heart failure (HF) about lifestyle changes to avoid complications. Which statement made by the patient indicates that further teaching is needed? A. "I can add salt to my food and eat what I want." ANS: A. I can add salt to my food and eat what I want Not following a low-sodium diet may lead to complications such as hypertension, edema, and other conditions. Fluid restriction is not usually prescribed for the patient with mild to moderate HF. However, in chronic HF, fluids are limited to 2 L/day. Use of ice pops and hard candy helps avoid thirst, which is a side effect of the HF medications. Lack of exercise does not increase a patient's sodium level. Taking medication at the prescribed times is correct and does not need further teaching. A patient that is suspected to have heart failure reports fatigue. The nurse recalls that what condition related to newly diagnosed heart failure causes fatigue? A. Impaired renal perfusion ANS: B. Decreased oxygenation of the tissues Fatigue is caused by decreased oxygenation of the tissues. Impaired renal perfusion resulting in decreased urine output during the day is a cause of nocturia, not fatigue. Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluids from the dependent body areas when the patient is lying flat. Dyspnea, not fatigue, is caused by an increased pulmonary pressure secondary to interstitial and alveolar edema. The nurse recalls that the decreased filling of the ventricles that is associated with diastolic failure results in what primary manifestation? A. Decreased afterload ANS: D. Decreased stroke volume (SV) and cardiac output (CO) Diastolic failure often is referred to as heart failure with normal ejection fraction. Decreased filling of the ventricles results in decreased stroke volume and CO. Diastolic failure is characterized by high filling pressures because of stiff ventricles. This results in venous engorgement in both the pulmonary and systemic vascular systems. The nurse assesses that a patient with acute decompensated heart failure (ADHF) experiences dyspnea. What is the priority nursing action? A. Perform ultrafiltration ANS: B. Provide supplemental oxygen Supplemental oxygen helps increase the percentage of oxygen in inspired air. Ultrafiltration is a process used to remove excess salt and water from the blood in case of volume overload. Mechanical ventilation is used in cases of pulmonary edema, to help decrease the preload. An ABG test will provide information about the amount of oxygen and carbon dioxide is in the blood, but it is not a priority. A patient that is diagnosed with heart failure experiences fatigue. The nurse suspects that the fatigue is caused by what? A. Increased cardiac output ANS: C. Impaired perfusion to vital organs Fatigue is one of the early signs of heart failure. Due to heart failure, there is inadequate blood circulation, leading to decreased perfusion to the vital organs. An impaired functioning of the vital organs may lead to fatigue. Cardiac output decreases in heart failure, depriving the body tissues of oxygen and nutrients, leading to fatigue. Inadequate blood supply results in inadequate oxygenation of the tissue and causes fatigue when the oxygen demands are not met. Hemoglobin levels are low in heart failure, leading to anemia. A decreased oxygen-carrying capacity of the blood also results in fatigue. A patient develops unexplained heart failure (HF) that remains unresponsive to usual therapy. For what diagnostic test does the nurse prepare the patient? A. Chest x-ray ANS: B. Echocardiogram An echocardiogram provides information on the ejection fraction (EF). It also provides information on the structure and function of the heart valves. Heart chamber enlargement or stiffness can also be assessed. An ECG and chest x-ray are also useful but are not as specific. Heart catheterization, such as coronary angiography, is performed to determine ejection fraction (EF) and blockages. A patient is diagnosed with paroxysmal nocturnal dyspnea. The nurse expects the patient to report what clinical manifestation? A. Decreased attention span ANS: D. Awakening from sleep with feelings of suffocation Paroxysmal nocturnal dyspnea occurs when the patient is asleep. The patient awakes in a state of panic with a feeling of suffocation and has a strong desire to sit or stand up. Breathlessness on exertion is called dyspnea. Shortness of breath when lying down, that is, orthopnea, often accompanies dyspnea. A decreased attention span is a behavioral change that may be due to poor gas exchange or worsening heart failure. While assessing a patient with acute decompensated heart failure (ADHF), the nurse auscultates fine crackles bilaterally. The nurse recognizes that crackles are an indicator of what? A. Atelectasis ANS: B. Fluid in the alveoli Fluid in the alveoli is the correct answer because crackles are made by the sound of air moving through fluid-filled alveoli. Atelectasis is the collapsing of alveoli and would not produce sound. Mucus in the airways sounds like rhonchi or would cause diminished lung sounds if there were consolidation. Bronchoconstriction results in wheezing. A patient with heart failure (HF) often experiences dyspnea and reports feeling very anxious during the dyspneic episodes. The nurse anticipates a prescription for what medication? A. Digoxin ANS: B. Morphine Morphine is an opioid analgesic used to both reduce anxiety and treat heart failure. Digoxin is a cardiac glycoside, which is used to increase cardiac contractility. Dopamine is a positive inotrope that is used to treat heart failure. Metolazone is a thiazide-like diuretic that is used to treat heart failure. The nurse is caring for a patient with left-sided heart failure and expects what assessment finding? A. Hepatomegaly ANS: C. Pulmonary congestion Left-sided heart failure results from left ventricular dysfunction; this is manifested as pulmonary congestion and edema. Venous congestion in the systemic circulation results in jugular venous distention, hepatomegaly, splenomegaly, vascular congestion of the gastrointestinal tract, and peripheral edema. A patient with chronic heart failure (HF) reports disturbed sleep due to the urge to urinate frequently. The nurse suspects that what condition that is associated with HF is most likely causing the patient's nocturia? A. Diabetes ANS: D. Extravascular fluid being reabsorbed from the interstitial spaces back into the circulatory system, resulting in increased perfusion to the kidneys In a patient with chronic heart failure, there is decreased renal perfusion and urine production during the day, because most fluid gets accumulated in the peripheral tissues. However, while lying down at night in a recumbent position, the fluid from the peripheral interstitial tissues enters the central circulation. This leads to an increase in renal function, causing nocturia. Diabetes, an enlarged prostate, and caffeine intake before going to bed also cause nocturia but are less likely in this case. The nurse is educating a patient about diastolic failure and should include what characteristic feature? A. High pulmonary pressures ANS: C. Inability of the ventricles to relax and fill Diastolic failure is the inability to relax and fill the ventricles during diastole. Systolic failure is the inability of the heart to pump blood effectively. Patients with mixed systolic and diastolic failure experience high pulmonary pressures. The EF is normal with diastolic failure. A nurse reviews the medical record of a patient with pulmonary embolism and notes the presence of cor pulmonale. The nurse recalls that this refers to a disorder of the heart that is caused by what? A. Liver disease ANS: C. Pulmonary disease Cor pulmonale is a cardiac condition in which a disease of the pulmonary system causes an increase in right ventricular pressure. This increased right ventricular pressure causes right ventricular failure, which may eventually lead to heart failure. This term is not used for heart disease caused by liver, kidney, or preexisting heart diseases. A patient is diagnosed with pulmonary edema. The nurse anticipates a prescription for which type of medication? A. Diuretic ANS: A. Diuretic Diuretics are used to treat pulmonary edema because they act on the ascending loop of Henle to promote sodium, chloride, and water excretion. Vasodilators cause dilation of the blood vessel wall. β-adrenergic blockers help counteract the negative effect of the sympathetic nervous system. Angiotensin-converting enzyme inhibitors block the enzyme that can cause angiotensin I to form angiotensin II, which is a potent vasoconstrictor. The nurse reviews the compensatory mechanisms an overloaded heart uses to try to maintain adequate cardiac output (CO). What is the order of events that occur when the sympathetic nervous system is activated? 1. Inadequate cardiac output The compensatory mechanism is activated when the CO is inadequate, which results in the increased release of catecholamines. Increased catecholamines cause constriction of the blood vessels, which causes preload of the heart to increase. Eventually, the cardiac output is increased. The nurse is caring for a patient developing pulmonary edema. What respiratory rate does the nurse anticipate when assessing this patient? A. 10 to 14 breaths/minute ANS: D. 32 to 36 breaths/minute A respiratory rate higher than 30 breaths/minute is often found in patients with pulmonary edema. A patient experiences dyspnea and orthopnea due to the accumulation of edematous fluid in the lung tissues, which affects the patient's respiratory rate. The respiratory rates in the ranges of 12 to 16, 16 to 20, and 20 to 24 breaths/minute indicate normal respiration. A patient with a history of left-sided heart failure arrives in the emergency department reporting extreme shortness of breath and a persistent cough with pink, frothy sputum. On auscultation of the heart, the nurse notes an S3 gallop. The nurse recognizes those symptoms as being caused by what? A. Pneumonia ANS: D. Acute pulmonary edema Extreme shortness of breath and a persistent cough with pink, frothy sputum are symptoms of pulmonary edema. Pneumonia, an asthma attack, and a myocardial infarction are not correct because pink frothy sputum and an S3 gallop are not symptoms of any of these. The nurse recalls that paroxysmal nocturnal dyspnea is a condition indicative of what more serious problem? A. COPD ANS: D. Heart failure A classic symptom of left-sided heart failure is paroxysmal nocturnal dyspnea, which awakens the patient after several hours of sleep. Although a patient with chronic obstructive pulmonary disease, asthma, or bronchitis may experience shortness of breath, these symptoms do not usually manifest while the patient is sleeping. The nurse reviews the teaching plan that has been created for a patient with chronic heart failure that is being discharged from the hospital. The nurse should question which item that is listed on the plan? A. Eat small, frequent meals. ANS: D. Immediately report a weight gain of 5 pounds in 2 days The patient should be instructed to immediately report a weight gain of 3 pounds in 2 days, or 3-5 pounds in a week. Eating small, frequent meals is a component of the dietary therapy. The patient should be instructed to receive the annual flu vaccination for health promotion. The patient should be instructed to avoid extremes of heat and cold, to prevent stress on the heart. The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment? A. Lung sounds ANS: A. Lung sounds The priority nursing assessment is auscultation of lung sounds. Excess fluid volume often leads to pulmonary congestion. ADHF can manifest as pulmonary edema. Facial swelling is a possible side effect with prescribed renin-angiotensin-aldosterone inhibitors for heart failure. It is important to assess the patient's anxiety, but it is not the priority. Assessing intake and output is important for right-sided heart failure. A patient with cardiac failure is scheduled to receive sodium nitroprusside. The nurse should monitor what parameter while administering the drug to the patient? A. Blood pressure ANS: A. Blood pressure Symptomatic hypotension is a major adverse effect of sodium nitroprusside; therefore, blood pressure is continuously monitored in patients taking sodium nitroprusside. Body temperature, heart rate, and central venous pressure are not altered due to administration of this drug. A patient is admitted to the hospital with a diagnosis of acute decompensated heart failure (ACHF). The primary health care provider prescribes a continuous intravenous infusion of sodium nitroprusside. What is the priority nursing intervention? A. Monitor urinary output. ANS: B. Monitor blood pressure The priority nursing intervention is to monitor blood pressure, because symptomatic hypotension is the main adverse effect of sodium nitroprusside. Monitoring urinary output is not necessary during a continuous intravenous infusion of sodium nitroprusside. Hyperkalemia may occur with renin-angiotensin-aldosterone inhibitors, angiotensin II receptor blockers, and aldosterone antagonists. Assessment is needed for the skin around an intravenous infusion of dopamine (Intropin) because it can cause tissue necrosis with sloughing. A nurse provides discharge instructions to a patient with chronic heart failure related to dietary restrictions. Which statement made by the patient indicates understanding of the teaching? A. "I should not use salt at the table." ANS: A. "I should not use salt at the table." Patients with heart failure should avoid salt because it contains sodium. Sodium tends to absorb water and increase edema, which may worsen heart failure. Bread, processed meat, and cheese contain high levels of sodium and should be avoided. Intake of milk should be restricted to only two cups daily because it is rich in fat. Lemon juice and spices can be used instead of salt to flavor food. A patient has undergone cardiac transplantation. The nurse expects that which treatment will be prescribed? A. Antibiotic therapy ANS: C. Immunosuppressive therapy Immunosuppressive therapy is used to suppress the immune system and prevent rejection of the transplanted heart. Intravenous immunoglobulin (IVIG) is a blood product that is administered intravenously. It contains the pooled, polyvalent, and IgG antibodies extracted from the plasma of over one thousand blood donors and is used to boost the immune system. Antibiotic therapy is used to prevent infection. Antifungal therapy is used to treat fungal infections. The assessment findings of a patient with myocardial infarction (MI) include jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute. The nurse suspects what complication? A. Left-sided HF ANS: B. Right-sided HF An MI is a primary cause of heart failure. Jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure, not left-sided HF, ADHF, or chronic HF. The nurse compares the signs and symptoms of right-sided heart failure and left-sided heart failure. Which symptom is unique to right-sided heart failure? A. Fatigue ANS: D. Bilateral edema Right-sided heart failure is manifested as bilateral edema in the patient. Fatigue, anxiety, and depression are symptoms of both right-sided and left-sided heart failure. What is the most probable cause of death in a patient in the first year after heart transplantation? A. Lymphoma ANS: B. Acute rejection Acute rejection of the graft could be the most probable cause of death within a year of cardiac transplantation. Other long-term causes may include lymphoma, sudden cardiac death, and cardiac vasculopathy. A patient who underwent cardiac transplantation exhibits signs of acute rejection. The nurse recognizes that which medication is often used as posttransplantation therapy to prevent this type of response? A. Ibuprofen ANS: C. Tacrolimus Tacrolimus is a calcineurin that is included in most immunosuppressive regimens. Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID) used to treat pain. Metoprolol is a beta-blocker that is used to treat hypertension. Acetaminophen is a nonsteroidal antiinflammatory drug (NSAID) that is used to treat pain and fever. A male patient with a long history of heart failure qualifies for hospice care. The nurse identifies what priority goal? A. Providing comfort and relieving suffering ANS: A. Providing comfort and relieving suffering The central focus of hospice care is the promotion of comfort and the prevention of suffering. Medications should be continued unless they are not tolerated. Patient education should continue, but providing comfort is paramount. Experimental therapies and surgeries are not commonly used in the care of hospice patients. The nurse recalls that which type of drug therapy is used to treat volume overload in patients with acute decompensated heart failure (ADHF)? A. Diuretics ANS: A. Diuretics Diuretics are used in patients with fluid overload, which helps them to decrease the sodium reabsorption at various sites within the nephrons. This helps with flushing out the sodium from the body and promotes water loss. Vasodilators improve coronary artery circulation by dilating the coronary artery. Narcotics, such as morphine sulfate, dilate both pulmonary and systematic blood vessels but may not help in fluid overload. Positive inotropes increase myocardial contractility and help in dilating renal blood vessels, enhancing renal output. The nurse reviews the laboratory results of a patient with heart failure (HF) and notes an increased calcium level and decreased magnesium level. The nurse should notify the health care provider of the findings and withhold which scheduled medication? A. Digoxin ANS: A. Digoxin Hypercalcemia and hypomagnesemia can trigger digitalis toxicity. The dose should be held, and the health care provider should be notified. The lab findings are not indications to withhold morphine sulfate, metoprolol, or spironolactone. The nurse is caring for a patient with chronic heart failure and atrial fibrillation that takes digoxin and a thiazide diuretic. Which statement made by the patient indicates that the patient is experiencing a complication related to the medication? A. "My ankles are still slightly swollen." ANS: C. "I'm not really hungry for lunch. I feel so nauseated and tired." Drug therapy with digoxin and potassium-losing diuretics (thiazides or loop diuretics) may lead to hypokalemia. The presence of hypokalemia while the patient is on digoxin may lead to digoxin toxicity. Signs of early digoxin toxicity include anorexia, nausea and vomiting, fatigue, headache, depression, and visual changes. Slightly swollen ankles are an expected finding with chronic heart failure; frequent urination is an expected effect of the diuretic. The heart rate of 90 beats/minute is normal. The nurse develops dietary education for a patient with heart failure (HF) and should include what information? A. A list of foods high in
thiamine ANS: B. Guidelines for a low-sodium diet A low-sodium diet is advised for heart failure patients. Protein levels should not be increased for heart failure patients. High levels of thiamine are not part of the dietary plan for heart failure patients. Fluid restrictions are not necessary for all patients and would not be as low as 500 mL. The nurse recognizes that a primary goal for a patient with chronic heart failure is what? A. Maximizing cardiac output ANS: A. Maximizing cardiac output An increase in cardiac output helps overcome chronic heart failure, thereby maintaining the blood flow to meet the body's demand. Being overweight is just one risk factor for chronic heart failure; maintaining ideal body weight may not be a goal for some patients. Performing daily aerobic exercises may be too strenuous on the heart. There are many risk factors to consider when determining treatment goals. Pulse oximetry is used to monitor the effectiveness of oxygen therapy, and achievement of a steady reading is not a practical or primary goal. A patient with heart failure complains of fatigue. The nurse understands that which causes of fatigue are associated with heart failure? A. Anemia ANS: A Anemia related to heart failure is caused by poor nutrition, renal disease, and angiotensin-converting enzyme. This leads to fatigue. Cardiac output is reduced, which in turn reduces perfusion to tissues and decreases oxygen delivery to tissues, leading to fatigue. During history-taking, the nurse notes that a patient consumes foods high in sodium, which contributes to the patient's hypertension. The nurse develops a dietary plan and should educate the patient to avoid which food item? A. Shrimp ANS: C. Canned soups Canned soups are high in sodium and should be avoided by patients with hypertension. Skinless chick breasts, spinach salad, fish, and shellfish are low in sodium and may be consumed on a low-sodium diet. A patient newly diagnosed with heart failure is being discharged from the hospital. Which health care team member frequently works with protocols set up with the patient's health care provider to identify problems and start interventions? A. Physical therapist ANS: B. Home health nurse Home health nurses frequently work with protocols set up with the patient's health care provider. The protocols help the patient to identify problems, such as an increase in weight or dyspnea, both of which are symptoms of worsening heart failure. Physical therapy or occupational therapy may not be needed. Social services can assist with obtaining community resources the patient may need. A patient with heart failure is being discharged from the hospital. Which instructions should the nurse include in the patient's teaching plan? A. Limit activity, including daily exercise. ANS: D. Report a weight gain of 3 lb (1.4 kg) in two days, or 3 to 5 lbs (2.3 kg) in a week Daily weight is the best indicator of changes in fluid status. An activity such as daily exercise is encouraged because exercise improves the patient's sense of well-being. A fluid restriction may be recommended for advanced heart failure but is not a method of monitoring fluid status. The patient should never adjust medications without consulting with the primary health care provider. Which heart failure disease causes fatigue?As your heart works overtime, it can cause tiredness, shortness of breath and a feeling of being simply worn out. Such are the signs of fatigue, one of the most common symptoms of congestive heart failure.
Which items in a patient's medical history are risk factors for heart failure HF )?Heart or blood vessel conditions, serious lung disease, or infections such as HIV or SARS-CoV-2 raise your risk. This is also true for long-term health conditions such as obesity, high blood pressure, diabetes, sleep apnea, chronic kidney disease, anemia, thyroid disease, or iron overload.
Which patient conditions increase the risk of developing heart failure?The most common conditions that can lead to heart failure are coronary artery disease, high blood pressure and previous heart attack. If you've been diagnosed with one of these conditions, it's critical that you manage it carefully to help prevent the onset of heart failure.
Which findings will the nurse likely observe when a patient has right sided heart failure?Shortness of breath (dyspnea), even after only a small amount of exertion. Weakness and lethargy. Fatigue. Swelling (edema), that often involves not only the ankles and lower extremities but also the thighs, abdomen, and chest.
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Quizlet a patient diagnosed with heart failure experiences fatigue. which factor causes the fatigue
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