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1. A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to
a. auscultate the lung sounds.
b. assess the orientation.
c. check the capillary refill.
d. palpate the abdomen.

Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. 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/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority.

Cognitive Level: Application Text Reference: pp. 824-825
Nursing Process: Assessment NCLEX: Physiological Integrity

2. A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to
a. ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of sodium in the patient's diet.
b. instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods.
c. assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring.
d. educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to reduce the hypervolemia.


Rationale: The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening; 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 and teaching about diuretic therapy are appropriate interventions but are not the first nursing actions indicated. There is no evidence that the patient's weight gain is caused by excessive dietary intake of fat or calories, so the answer beginning "instruct the patient in a low-calorie, low-fat diet" describes an inappropriate action.

Cognitive Level: Application Text Reference: p. 826
Nursing Process: Assessment NCLEX: Physiological Integrity

3. During assessment of a 72-year-old with ankle swelling, the nurse 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. incompetent jugular vein valves.
c. elevated right atrial pressure.
d. jugular vein atherosclerosis.

Rationale: 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 elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume; it is not caused by incompetent jugular vein valves or atherosclerosis.

Cognitive Level: Comprehension Text Reference: p. 825
Nursing Process: Assessment NCLEX: Physiological Integrity

4. The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is
a. weight loss of 2 pounds overnight.
b. improvement in hourly urinary output.
c. reduction in systolic BP.
d. decreased dyspnea with the head of the bed at 30 degrees.

Rationale: 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 crackles. The other assessment data also may indicate that diuresis or improvement in cardiac output have occurred but are not as useful in evaluating this patient's response.

Cognitive Level: Application Text Reference: p. 825
Nursing Process: Evaluation NCLEX: Physiological Integrity

5. When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that
a. hypertensive crisis may lead to development of acute heart failure in some patients.
b. hypertension eventually will lead to heart failure by overworking the heart muscle.
c. high BP increases risk for rheumatic heart disease.
d. high systemic pressure precipitates papillary muscle rupture.

Rationale: Hypertension is a primary cause of heart failure because the increase in ventricular afterload leads to ventricular hypertrophy and dilation. Hypertensive crisis may precipitate acute heart failure is some patients, but this patient with stage 1 hypertension may not be concerned about a crisis that happens only to some patients. Hypertension does not directly cause rheumatic heart disease (which is precipitated by infection with group A -hemolytic streptococcus) or papillary muscle rupture (which is caused by myocardial infarction/necrosis of the papillary muscle).

Cognitive Level: Application Text Reference: p. 822
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance

6. A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to
a. administer IV morphine sulfate 2 mg.
b. give IV diazepam (Valium) 2.5 mg.
c. increase dopamine (Intropin) infusion by 2 mcg/kg/min.
d. increase nitroglycerin (Tridil) infusion by 5 mcg/min.

Rationale: 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 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.

Cognitive Level: Analysis Text Reference: pp. 828-829
Nursing Process: Implementation NCLEX: Physiological Integrity

7. Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops
a. a drop in heart rate to 54 beats/min.
b. a systolic BP <90 mm Hg.
c. any symptoms indicating cyanide toxicity.
d. an increased amount of ventricular ectopy.

Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. After 48 hours of continuous use, cyanide toxicity is a possible (though rare) adverse effect. Reflex tachycardia (not bradycardia) is another adverse effect of this medication. Nitroprusside does not cause increased ventricular ectopy.

Cognitive Level: Application Text Reference: p. 828
Nursing Process: Evaluation NCLEX: Physiological Integrity

8. A patient admitted to the hospital with an exacerbation of 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!" The nurse can best document this assessment information as
a. pulsus alternans.
b. paroxysmal nocturnal dyspnea.
c. two-pillow orthopnea.
d. acute bilateral pleural effusion.

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.

Cognitive Level: Comprehension Text Reference: p. 825
Nursing Process: Assessment NCLEX: Physiological Integrity

9. During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is
a. activity intolerance related to venous congestion.
b. disturbed body image related to massive leg swelling.
c. impaired skin integrity related to peripheral edema.
d. impaired gas exchange related to chronic heart failure.

Rationale: The patient's findings of severe dependent edema and weeping serous fluid from the legs support the nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance, disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate.

Cognitive Level: Application Text Reference: p. 836
Nursing Process: Diagnosis NCLEX: Physiological Integrity

10. The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient
a. says that the nitroglycerin patch will be used for any chest pain that develops.
b. calls when the weight increases from 124 to 130 pounds in a week.
c. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime.
d. makes an appointment to see the doctor at least once yearly.

Rationale: 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 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 necessary" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. Heart failure is a chronic condition that will require frequent follow-up rather than an annual health care provider examination.

Cognitive Level: Application Text Reference: pp. 826, 833-834, 838
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance

11. When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as
a. administering sedatives to promote rest and decrease myocardial oxygen demand.
b. positioning the patient in a high-Fowler's position with the feet horizontal in the bed.
c. administering oxygen per mask or nasal cannula.
d. encouraging leg exercises to improve venous return.

Rationale: Positioning the patient in a high-Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload.

Cognitive Level: Application Text Reference: pp. 827-828
Nursing Process: Planning NCLEX: Physiological Integrity

12. When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include
a. eggs and other high-cholesterol foods.
b. canned and frozen fruits.
c. fresh or frozen vegetables.
d. milk, yogurt, and other milk products.

Rationale: 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.

Cognitive Level: Application Text Reference: p. 833
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

13. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the patient include
a. avoid dietary sources of potassium because too much can cause digitalis toxicity.
b. take the pulse rate daily and never take digoxin if the pulse is below 60 beats/min.
c. take the hydrochlorothiazide before bedtime to maximize activity level during the day.
d. notify the health care provider immediately if nausea or difficulty breathing occurs.

Rationale: Difficulty breathing is an indication of acute decompensated heart failure and suggests that the medications are not achieving the desired effect. 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. Digoxin toxicity is potentiated by hypokalemia, rather than hyperkalemia. 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.

Cognitive Level: Application Text Reference: p. 835
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

14. The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned about
a. an apical pulse rate of 106 beats/min.
b. an oxygen saturation of 88% on room air.
c. weight gain of 1 kg (2.2 lb) over 24 hours.
d. decreased hourly patient urinary output.

Rationale: 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 rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.

Cognitive Level: Analysis Text Reference: pp. 829-830
Nursing Process: Assessment NCLEX: Physiological Integrity

15. While admitting an 80-year-old patient with heart failure to the medical unit, the nurse obtains the information that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." The nurse makes a note that discharge planning for the patient will need to include
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.

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 to 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.

Cognitive Level: Application Text Reference: pp. 836-837
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

16. A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's
a. weight increases from 120 pounds to 122 pounds over 3 days.
b. liver is palpable 2 cm below the ribs on the right side.
c. serum potassium level is 3.0 mEq/L after 1 week of therapy.
d. has 1 to 2+ edema in the feet and ankles in the morning.

Rationale: Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

Cognitive Level: Application Text Reference: pp. 832-833
Nursing Process: Assessment NCLEX: Physiological Integrity

17. Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about
a. digitalis preparations, such as digoxin (Lanoxin).
b. calcium-channel blockers, such as diltiazem (Cardizem).
c. -adrenergic agonists, such as dobutamine (Dobutrex).
d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).

Rationale: 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 -adrenergic blockers is insufficient. Calcium-channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure.

Cognitive Level: Application Text Reference: p. 832
Nursing Process: Implementation NCLEX: Physiological Integrity

18. A 55-year-old patient with inoperable coronary artery disease and end-stage heart failure asks the nurse whether heart transplant is a possible therapy. The nurse's response to the patient will be based on the knowledge that
a. heart transplants are experimental surgeries that are not covered by most insurance.
b. the patient is too old to be placed on the transplant list.
c. the diagnoses and symptoms indicate that the patient is not an appropriate candidate.
d. candidacy for heart transplant depends on many factors.

Rationale: Indications for a heart transplant include inoperable coronary artery disease and refractory end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous post-transplant regimen are also considered. Heart transplants are not considered experimental; rather, transplantation has become the treatment of choice for patients who meet the criteria. The patient is not too old for a transplant. The patient's diagnoses and symptoms indicate that the patient may be an appropriate candidate for a heart transplant.

Cognitive Level: Comprehension Text Reference: p. 837
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance

19. An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient
a. has BP of 88/42.
b. has an apical pulse rate of 56.
c. complains of feeling tired.
d. has 2+ pedal edema.

Rationale: The patient's BP indicates that the dose of carvedilol may need to be decreased because the mean arterial pressure is only 57. Bradycardia is a frequent adverse effect of -Adrenergic blockade, but the rate of 56 is not as great a concern as the hypotension. -adrenergic blockade will initially 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.

Cognitive Level: Application Text Reference: p. 832
Nursing Process: Assessment NCLEX: Analysis

20. An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is
a. 12-lead electrocardiogram (ECG).
b. arterial blood gases (ABGs).
c. B-type natriuretic peptide (BNP).
d. serum creatine kinase (CK).

Rationale: BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

Cognitive Level: Application Text Reference: p. 827
Nursing Process: Assessment NCLEX: Physiological Integrity

21. A patient with ADHF who is receiving nesiritide (Natrecor) asks the nurse how the medication will work to help improve the symptoms of dyspnea and orthopnea. The nurse's reply will be based on the information that nesiritide will
a. dilate arterial and venous blood vessels, decreasing ventricular preload and afterload.
b. improve the ability of the ventricular myocardium to contract, strengthening contractility.
c. enhance the speed of impulse conduction through the heart, increasing the heart rate.
d. increase calcium sensitivity in vascular smooth muscle, boosting systemic vascular resistance.

Rationale: Nesiritide, a recombinant form of BNP, causes both arterial and venous vasodilation, leading to reductions in preload and afterload. Inotropic medications, such as dopamine and dobutamine, may be used in ADHF to improve ventricular contractility. Nesiritide does not increase impulse conduction or calcium sensitivity in the heart.

Cognitive Level: Application Text Reference: p. 829
Nursing Process: Implementation NCLEX: Physiological Integrity

22. A patient who is receiving dobutamine (Dobutrex) for the treatment of ADHF has all of the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN?
a. Teach the patient the reasons for remaining on bed rest.
b. Monitor the patient's BP every hour.
c. Adjust the drip rate to keep the systolic BP >90 mm Hg.
d. Call the health care provider about a decrease in urine output.

Rationale: An experienced LPN/LVN would be able to monitor BP and would know to report significant changes to the RN. Teaching patients and making adjustments to the drip rate for vasoactive medications are RN-level skills. Because the health care provider may order changes in therapy based on the decrease in urine output, the RN should call the health care provider about the decreased urine output.

Cognitive Level: Application Text Reference: pp. 827-829
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

23. A hospitalized 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 captopril, which statement by the patient indicates that teaching has been effective?
a. "I will need to include more high-potassium foods in my diet."
b. "I will expect to feel more short of breath for the next few days."
c. "I will be sure to take the medication after eating something."
d. "I will call for help when I need to get up to the bathroom."

Rationale: 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 ACE inhibitors are potassium sparring, and the nurse should not teach the patient to increase sources of dietary potassium. Increased shortness of breath is expected with initiation of -blocker therapy for heart failure, not for ACE-inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

Cognitive Level: Application Text Reference: p. 832
Nursing Process: Evaluation NCLEX: Physiological Integrity

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