Chapter 35: Nursing Management: Heart Failure

Chapter 35: Nursing Management: Heart Failure

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE
1. 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. jugular vein atherosclerosis.
c. elevated 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 elevated 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: Comprehension REF: 802
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. 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. hourly urine output greater than 60 mL.
c. reduction in patient complaints of chest pain.
d. decreased dyspnea with the head of bed at 30 degrees.
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
also may indicate that diuresis or improvement in cardiac output has occurred but are not
as specific to evaluating this patient’s response.
DIF: Cognitive Level: Application REF: 804-806 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 38%?
a. Need to participate in an aerobic exercise program several times weekly
Test Bank 35-2
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Importance of making a yearly appointment with the primary care provider
d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
ANS: D
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: Application REF: 812 TOP: Nursing Process:
Planning
MSC: NCLEX: Physiological Integrity
4. 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
nitroprusside rate if the patient develops
a. a dry, hacking cough.
b. any ventricular ectopy.
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: Application REF: 804-805 TOP: Nursing Process:
Evaluation
MSC: NCLEX: Physiological Integrity