Medical-Surgical Nursing Assessment and Management of Clinical Problems 9e Chapter 35

Chapter 35: Nursing Management: Heart Failure
Test Bank
MULTIPLE CHOICE
1. While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention
(JVD) with the head of the patients 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: 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.
DIF: Cognitive Level: Understand (comprehension) REF: 769

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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 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: D
Because the patients 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 patients response.
DIF: Cognitive Level: Apply (application) REF: 769-770 | 773-774

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
3. 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: 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.
DIF: Cognitive Level: Apply (application) REF: 767 | 776 | 779

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
4. 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: 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.
DIF: Cognitive Level: Apply (application) REF: 774

5. 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. pulsus alternans.
c. paroxysmal nocturnal dyspnea.
d. acute bilateral pleural effusion.
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. 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.
DIF: Cognitive Level: Remember (knowledge) REF: 770-771

6. 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: A
The patients 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.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
7. 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: 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 nocturia 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.

8. 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: 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.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
9. The nurse plans discharge teaching for a patient with chronic heart failure who has
prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate
instructions for the patient include
a. limit dietary sources of potassium.
b. take the hydrochlorothiazide before bedtime.
c. notify the health care provider if nausea develops.
d. skip the digoxin if the pulse is below 60 beats/minute.
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.

10. 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 patients 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: 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 patients 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.

11. 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.
b. b-adrenergic blockers.
c. calcium channel blockers.
d. angiotensin-converting enzyme (ACE) inhibitors.
ANS: D
ACE inhibitor therapy is currently recommended to prevent the development of heart failure
in patients who have had a myocardial infarction and as a first-line therapy for patients with
chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line
measure, and digoxin is added to the treatment protocol when therapy with other medications
such as ACE-inhibitors, diuretics, and b-adrenergic blockers is insufficient. Calcium channel
blockers are not generally used in the treatment of heart failure. The b-adrenergic blockers are
not used as initial therapy for new onset heart failure.

12. A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether
heart transplant is a possible therapy. Which response by the nurse is most appropriate?
a. Because you have diabetes, you would not be a candidate for a heart transplant.
b. The choice of a patient for a heart transplant depends on many different factors.
c. Your heart failure has not reached the stage in which heart transplants are
needed.
d. People who have heart transplants are at risk for multiple complications after
surgery.
ANS: B
Indications for a heart transplant include end-stage heart failure (Stage D), but other factors
such as coping skills, family support, and patient motivation to follow the rigorous
posttransplant regimen are also considered. Diabetic patients who have well-controlled blood
glucose levels may be candidates for heart transplant. Although heart transplants can be
associated with many complications, this response does not address the patients question.

13. Which diagnostic test will be most useful to the nurse in determining whether a patient
admitted with acute shortness of breath has heart failure?
a.Serum troponin
b.Arterial blood gases
c.B-type natriuretic peptide
d.12-lead electrocardiogram
ANS: C
B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do
with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart
failure. A twelve-lead electrocardiogram, arterial blood gases, and troponin may also be used
in determining the causes or effects of heart failure but are not as clearly diagnostic of heart
failure as BNP.

14. Which action should the nurse include in the plan of care when caring for a patient admitted
with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?
a. Monitor blood pressure frequently.
b. Encourage patient to ambulate in room.
c. Titrate nesiritide slowly before stopping.
d. Teach patient about home use of the drug.
ANS: A
Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension.
Because the patient is likely to have orthostatic hypotension, the patient should not be
encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in
a home setting.

15. A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After
administering the first dose and teaching the patient about the drug, which statement by the
patient indicates that teaching has been effective?
a. I will be sure to take the medication with food.
b. I will need to eat more potassium-rich foods in my diet.
c. I will call for help when I need to get up to use the bathroom.
d. I will expect to feel more short of breath for the next few days.
ANS: C
Captopril can cause hypotension, especially after the initial dose, so it is important that the
patient not get up out of bed without assistance until the nurse has had a chance to evaluate the
effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium
sparing, and the nurse should not teach the patient to purposely increase sources of dietary
potassium. Increased shortness of breath is expected with the initiation of b-adrenergic
blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best
absorbed when taken an hour before eating.

16. A patient who has just been admitted with pulmonary edema is scheduled to receive the
following medications. Which medication should the nurse question before giving?
a. Furosemide (Lasix) 60 mg
b. Captopril (Capoten) 25 mg
c. Digoxin (Lanoxin) 0.125 mg
d. Carvedilol (Coreg) 3.125 mg
ANS: D
Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for
patients with acute decompensated heart failure (ADHF) because of the risk of worsening the
heart failure. The other medications are appropriate for the patient with ADHF.
DIF: Cognitive Level: Analyze (analysis) REF: 774 | 771

17. 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 action should the nurse do first?
a. Auscultate the abdomen.
b. Check the capillary refill.
c. Auscultate the breath sounds.
d. Assess the level of orientation.
ANS: C
This patients 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/respiratory
arrest. The other assessments will provide useful data about the patients volume status and
also should be accomplished rapidly, but detection (and treatment) of pulmonary
complications is the priority.
DIF: Cognitive Level: Apply (application) REF: 769-770

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
18. A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting
enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a
5-pound weight gain in the last 3 days. The nurses priority action will be to
a. have the patient recall the dietary intake for the last 3 days.
b. ask 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 restricting dietary sodium.
ANS: C
The 5-pound weight gain over 3 days indicates that the patients chronic heart failure may be
worsening. It is important that the patient be assessed immediately 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.

19. A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains
of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following
medications have been ordered for the patient. The nurses priority action will be to
a. give IV morphine sulfate 4 mg.
b. give IV diazepam (Valium) 2.5 mg.
c. increase nitroglycerin (Tridil) infusion by 5 mcg/min.
d. increase dopamine (Intropin) infusion by 2 mcg/kg/min.
ANS: A
Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular
preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of
dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or
gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase
the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output
and may be appropriate for this patient, but it will not directly reduce anxiety and will not act
as quickly as morphine to decrease dyspnea.
DIF: Cognitive Level: Analyze (analysis) REF: 774

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
20. After receiving change-of-shift report on a heart failure unit, which patient should the nurse
assess first?
a. A patient who is cool and clammy, with new-onset confusion and restlessness
b. A patient who has crackles bilaterally in the lung bases and is receiving oxygen.
c. A patient who had dizziness after receiving the first dose of captopril (Capoten)
d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of
100/62
ANS: A
The patient who has wet-cold clinical manifestations of heart failure is perfusing
inadequately and needs rapid assessment and changes in management. The other patients also
should be assessed as quickly as possible but do not have indications of severe decreases in
tissue perfusion.

OBJ: Special Questions: Prioritization; Multiple Patients
21. Which assessment finding in a patient admitted with acute decompensated heart failure
(ADHF) requires the most immediate action by the nurse?
a. Oxygen saturation of 88%
b. Weight gain of 1 kg (2.2 lb)
c. Heart rate of 106 beats/minute
d. Urine output of 50 mL over 2 hours
ANS: A
A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should
administer supplemental oxygen immediately to the patient. An increase in apical pulse rate,
1-kg weight gain, and decreases in urine output also indicate worsening heart failure and
require nursing actions, but the low oxygen saturation rate requires the most immediate
nursing action.

22. A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and
captopril (Capoten) for the management of heart failure. Which assessment finding by the
home health nurse is a priority to communicate to the health care provider?
a. Presence of 1 to 2+ edema in the feet and ankles
b. Palpable liver edge 2 cm below the ribs on the right side
c. Serum potassium level 3.0 mEq/L after 1 week of therapy
d. Weight increase from 120 pounds to 122 pounds over 3 days
ANS: C
Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature
ventricular contractions), and potentiate the actions of digoxin and increase the risk for
digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate
that the patients heart failure requires more effective therapies, but they do not require
nursing action as rapidly as the low serum potassium level.

23. An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with
metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to
the health care provider?
a. 2+ pedal edema
b. Heart rate of 56 beats/minute
c. Blood pressure (BP) of 88/42 mm Hg
d. Complaints of fatigue
ANS: C
The patients BP indicates that the dose of metoprolol may need to be decreased because of
hypotension. Bradycardia is a frequent adverse effect of b-adrenergic blockade, but the rate of
56 is not unusual with -adrenergic blocker therapy. b-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.

24. A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated
heart failure (ADHF) has the following nursing interventions included in the plan of care.
Which action will be most appropriate for the registered nurse (RN) to delegate to an
experienced licensed practical/vocational nurse (LPN/LVN)?
a. Assess the IV insertion site for signs of extravasation.
b. Teach the patient the reasons for remaining on bed rest.
c. Monitor the patients blood pressure and heart rate every hour.
d. Titrate the rate to keep the systolic blood pressure >90 mm Hg.
ANS: C
An experienced LPN/LVN would be able to monitor BP and heart rate and would know to
report significant changes to the RN. Teaching patients, making adjustments to the drip rate
for vasoactive medications, and monitoring for serious complications such as extravasation
require RN level education and scope of practice.

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
25. After receiving change-of-shift report on a heart failure unit, which patient should the nurse
assess first?
a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58
b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L
c. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache
d. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough
ANS: B
The patients low potassium level increases the risk for digoxin toxicity and potentially fatal
dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then
notify the health care provider about the potassium level. The other patients also have side
effects of their medications, but their symptoms do not indicate potentially life-threatening
complications.

OBJ: Special Questions: Prioritization; Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Based on the Joint Commission Core Measures for patients with heart failure, which topics
should the nurse include in the discharge teaching plan for a patient who has been hospitalized
with chronic heart failure (select all that apply)?
a. How to take and record daily weight
b. Importance of limiting aerobic exercise
c. Date and time of follow-up appointment
d. Symptoms indicating worsening heart failure
e. Actions and side effects of prescribed medications
ANS: A, C, D, E
The Joint Commission Core Measures state that patients should be taught about prescribed
medications, follow-up appointments, weight monitoring, and actions to take for worsening
symptoms. Patients with heart failure are encouraged to begin or continue aerobic exercises
such as walking, while self-monitoring to avoid excessive fatigue.


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Chapter 35: Nursing Management: Heart Failure

DIF: Cognitive Level: Understand (comprehension) REF: 769

DIF: Cognitive Level: Apply (application) REF: 769-770 | 773-774

DIF: Cognitive Level: Apply (application) REF: 767 | 776 | 779

DIF: Cognitive Level: Apply (application) REF: 774

DIF: Cognitive Level: Remember (knowledge) REF: 770-771

DIF: Cognitive Level: Apply (application) REF: 770

DIF: Cognitive Level: Apply (application) REF: 771

DIF: Cognitive Level: Apply (application) REF: 778

DIF: Cognitive Level: Apply (application) REF: 777

DIF: Cognitive Level: Apply (application) REF: 783

DIF: Cognitive Level: Apply (application) REF: 776

DIF: Cognitive Level: Apply (application) REF: 783

DIF: Cognitive Level: Apply (application) REF: 772

DIF: Cognitive Level: Apply (application) REF: 774

DIF: Cognitive Level: Apply (application) REF: 776

DIF: Cognitive Level: Analyze (analysis) REF: 774 | 771

DIF: Cognitive Level: Apply (application) REF: 769-770

DIF: Cognitive Level: Apply (application) REF: 771

DIF: Cognitive Level: Analyze (analysis) REF: 774

DIF: Cognitive Level: Analyze (analysis) REF: 770

DIF: Cognitive Level: Apply (application) REF: 769-770

DIF: Cognitive Level: Apply (application) REF: 777

DIF: Cognitive Level: Apply (application) REF: 777

DIF: Cognitive Level: Apply (application) REF: 15-16

DIF: Cognitive Level: Analyze (analysis) REF: 777

DIF: Cognitive Level: Apply (application) REF: 779

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