The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)?
A Fatigue, orthopnea, and dependent edema
B Severe dyspnea and blood-streaked, frothy ...
The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which
clinical manifestations, if assessed by the nurse, would indicate acute decompensated heart
failure (pulmonary edema)?
A Fatigue, orthopnea, and dependent edema
B Severe dyspnea and blood-streaked, frothy sputum
C Temperature is 100.4o F and pulse is 102 beats/minute
D Respirations 26 breaths/minute despite oxygen by nasal cannula - ANS B Severe
dyspnea and blood-streaked, frothy sputum
Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold
skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths
per minute, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged
sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the
lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.
A 54-year-old male patient who had bladder surgery 2 days ago develops acute
decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be
indicated first?
A Perform a bladder scan to assess for urinary retention.
B Restrict the patient's oral fluid intake to 500 mL per day.
C Assist the patient to a sitting position with arms on the overbed table.
D Instruct the patient to use pursed-lip breathing until the dyspnea subsides. - ANS C
Assist the patient to a sitting position with arms on the overbed table.
The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal
in the bed or dangling at the bedside. This position helps decrease venous return because of
the pooling of blood in the extremities. This position also increases the thoracic capacity,
allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not
with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.
A70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin
has been prescribed for her to continue at home. Which response by the nurse is accurate?
, A "The medication prevents blood clots from forming in your heart."
B "The medication dissolves clots that develop in your coronary arteries."
C "The medication reduces clotting by decreasing serum potassium levels."
D "The medication increases your heart rate so that clots do not form in your heart." - ANS
A "The medication prevents blood clots from forming in your heart."
Chronic heart failure causes enlargement of the chambers of the heart and an altered electrical
pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly,
atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an
increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or
anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin
K-dependent clotting factors.
The nurse prepares to administer digoxin 0.125 mg to an 82-year-old man admitted with
influenza and a history of chronic heart failure. What should the nurse assess before giving the
medication?
A Prothrombin time
B Urine specific gravity
C Serum potassium level
D Hemoglobin and hematocrit - ANS C Serum potassium level
Serum potassium should be monitored because hypokalemia increases the risk for digoxin
toxicity. Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit
would not require holding the digoxin dose.
At a clinic visit, the nurse provides dietary teaching for a 56-year-old woman who was recently
hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is
successful if the patient makes which statement?
A "I will limit the amount of milk and cheese in my diet."
B "I can add salt when cooking foods but not at the table."
C "I will take an extra diuretic pill when I eat a lot of salt."
D "I can have unlimited amounts of foods labeled as reduced sodium ." - ANS A "I will limit
the amount of milk and cheese in my diet."
Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt
should not be added during food preparation or at the table. Diuretics should be taken as
prescribed (usually daily) and not based on sodium intake. Foods labeled as reduced sodium
contain at least 25% less sodium than regular.
The nurse is administering a dose of digoxin to a patient with heart failure (HF). The nurse
would become concerned with the possibility of digitalis toxicity if the patient reported which
symptom(s)?
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