Adams4e Tif Ch26

Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/EChapter 26Question 1Type: MCSA

The patient has hypertension and asks the nurse how this can lead to heart failure. What is the best response by the nurse?

1. "Hypertension causes resistance in your blood vessels, or afterload; your heart works harder, and weakens."

2. "Hypertension limits the ability of your heart to stretch before emptying, or afterload; your heart works harder, and weakens."

3. "Hypertension causes resistance in your aorta, or afterload; your heart works harder and weakens."

4. "Hypertension limits the amount of blood entering your left ventricle, or afterload; your heart works harder, and weakens."

Correct Answer: 1

Rationale 1: The most common cause of increased afterload is an increase in peripheral resistance due to hypertension. Afterload refers to peripheral resistance, not to the amount of blood entering the left ventricle. The ability of the heart to stretch before entering is known as preload, not afterload. Afterload refers to peripheral resistance, not to resistance in the aorta.




Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub:

Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 26-3

Question 2Type: MCMA

The patient comes to the emergency department complaining of coughing and difficulty breathing. The patient's diagnosis is heart failure. He asks the nurse how difficulty breathing could be a heart problem. What is the best response by the nurse?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. "The right side of your heart has weakened and blood has entered your lungs."

2. "The right side of your heart has enlarged and cannot effectively pump blood."

3. "What you have is called congestive heart failure."

4. "The left side of your heart is weak and pumps blood too quickly."

5. "The left side of your heart has weakened and blood has entered your lungs."

Correct Answer: 3,5

Rationale 1: When the left ventricle cannot compensate for increased preload, blood backs up into the lungs resulting in cough and shortness of breath. Left heart failure is sometimes called congestive heart failure. Left-sided, not right-sided, heart failure is associated with pulmonary congestion. Right-sided heart failure results in peripheral edema, not pulmonary congestion. Heart failure results from the inability of the left ventricle to pump blood, not pumping blood too quickly.



Rationale 4: When the left ventricle cannot compensate for increased preload, blood backs up into the lungs resulting in cough and shortness of breath. Left heart failure is sometimes called congestive heart failure. Left-sided, not right sided, heart failure is associated with pulmonary congestion. Right-sided heart failure results in Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

peripheral edema, not pulmonary congestion. Heart failure results from the inability of the left ventricle to pump blood, not pumping blood too quickly.


Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 26-2


The nurse teaches the patient about digoxin (Lanoxin) toxicity and determines that learning has occurred when the patient makes which statement(s)?



1. "I should limit my fluids while taking this medication."

2. "It is okay to keep taking my ginseng."

3. "If I have nausea, it means I must stop the medication."

4. "I can drink orange juice every morning."

5. "I must check my pulse and not take the medication if it is less than 60."

Correct Answer: 3,4,5

Rationale 1: Orange juice is a source of potassium, which will minimize the risk for digoxin (Lanoxin) toxicity. Nausea, by itself, may be a side effect, but it is not necessarily indicative of digoxin (Lanoxin) toxicity. Sixty beats per minute is the generally accepted limit for withholding digoxin (Lanoxin). Ginseng may increase the risk of digoxin (Lanoxin) toxicity. Dehydration can increase the risk for digoxin (Lanoxin) toxicity; the patient must not limit fluids.

Rationale 2: Orange juice is a source of potassium, which will minimize the risk for digoxin (Lanoxin) toxicity. Nausea, by itself, may be a side effect, but it is not necessarily indicative of digoxin (Lanoxin) toxicity. Sixty Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

beats per minute is the generally accepted limit for withholding digoxin (Lanoxin). Ginseng may increase the risk of digoxin (Lanoxin) toxicity. Dehydration can increase the risk for digoxin (Lanoxin) toxicity; the patient must not limit fluids.




Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 26-5

Question 4Type: MCSA

The nurse teaches the patient about lisinopril (Prinivil) and evaluates that additional teaching is required when the patient makes which statement?

1. "I will monitor my blood pressure until my next appointment."

2. "I will avoid using salt substitutes for seasoning."

3. "It takes a while for this medication to take effect."

4. "I don't need to worry about having blood tests done."

Correct Answer: 4


Rationale 1: The use of ACE inhibitors can lead to neutropenia, and the patient should be monitored for this side effect by having his absolute neutrophil count (ANC) measured. Potassium should be limited to avoid hyperkalemia. Blood pressure should be monitored to assess effectiveness of the medication. It takes a while for lisinopril (Prinivil) to become effective.




Global Rationale:



The patient will receive an IV infusion of milrinone (Primacor) as treatment for acute heart failure. What is the priority plan by the nurse?

1. Plan to monitor for atrial fibrillation.

2. Plan to monitor the ECG continuously.

3. Plan to take vital signs every 15 minutes.

4. Plan to monitor for hypertension.

Correct Answer: 2

Rationale 1: The patient's ECG is usually monitored continuously during the infusion of milrinone (Primacor). Vital signs should be assessed continuously, not every 15 minutes, while the patient receives milrinone


(Primacor). Hypotension, not hypertension, is an adverse effect of milrinone (Primacor). Ventricular dysrhythmias, not atrial fibrillation, are an adverse effect of milrinone (Primacor).

Rationale 2: The patient's ECG is usually monitored continuously during the infusion of milrinone (Primacor). Vital signs should be assessed continuously, not every 15 minutes, while the patient receives milrinone (Primacor). Hypotension, not hypertension, is an adverse effect of milrinone (Primacor). Ventricular dysrhythmias, not atrial fibrillation, are an adverse effect of milrinone (Primacor).



Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 26-4


The physician orders metoprolol (Toprol-XL) for several patients. The nurse will hold the medication and contact the physician for which patient?

1. The patient with an apical pulse rate of 100

2. The patient with compensated heart failure

3. The patient with chronic bronchitis

4. The patient with a history of migraines

Correct Answer: 3

Rationale 1: Beta-blockers are contraindicated for patients with chronic bronchitis. Beta-blockers may be used for patients with migraines. Beta-blockers may be used for patients with compensated heart failure. Beta-blockers may be used for patients with apical pulse rates of 100.





Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 26-6


The patient receives digoxin (Lanoxin). Which assessment findings would indicate adverse effects to this medication?

1. Tachycardia and hypotension

2. Blurred vision and tachycardia

3. Anorexia and nausea

4. Anorexia and constipation

Correct Answer: 3

Rationale 1: Anorexia and nausea are common adverse effects of digoxin (Lanoxin). Hypotension can occur, but bradycardia occurs, not tachycardia. Blurred vision can occur, but bradycardia occurs, not tachycardia. Anorexia can occur, but diarrhea is more likely than constipation.


Rationale 3: Anorexia and nausea are common adverse effects of digoxin (Lanoxin). Hypotension can occur, but bradycardia occurs, not tachycardia. Blurred vision can occur, but bradycardia occurs, not tachycardia. Anorexia can occur, but diarrhea is more likely than constipation.Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.


Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 26-7


The nurse volunteers at a senior citizen center. The nurse assesses which senior citizen as having the greatest risk of developing heart failure?

1. A 50-year-old black female who smokes

2. A 75-year-old white male who is overweight

3. A 69-year-old black male with hypertension

4. A 52-year-old white female with asthma

Correct Answer: 3

Rationale 1: Age, race, and hypertension lead to an increased risk for developing hypertension. Race and smoking are risk factors, but being female and younger decreases the overall risk. Age and obesity are risk factors, but not as much as age, black race, and hypertension. Asthma, by itself, is not considered a significant risk factor in the development of heart failure.



Rationale 4: Age, race, and hypertension lead to an increased risk for developing hypertension. Race and smoking are risk factors, but being female and younger decreases the overall risk. Age and obesity are risk factors, but not as much as age, black race, and hypertension. Asthma, by itself, is not considered a significant risk factor in the development of heart failure.Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 26-1


The patient receives furosemide (Lasix) and digoxin (Lanoxin) together. Which laboratory findings will the nurse assess as increasing the patient's risk for digoxin (Lanoxin) toxicity?

1. Hyponatremia and hyperkalemia

2. Hypermagnesemia and hyponatremia

3. Hypercalcemia and hyperkalemia

4. Hypokalemia and hypocalcemia

Correct Answer: 4

Rationale 1: Hypokalemia and hypocalcemia can result from an interaction with furosemide (Lasix) and digoxin (Lanoxin), so it will increase a patient's risk for digoxin (Lanoxin) toxicity. Hypercalcemia and hyperkalemia do not result from an interaction with furosemide (Lasix) and digoxin (Lanoxin), so it will not increase the patient's risk for digoxin (Lanoxin) toxicity. Hypermagnesemia and hyponatremia do not result from an interaction with furosemide (Lasix) and digoxin (Lanoxin), so it will not increase the patient's risk for digoxin (Lanoxin) toxicity. Hyponatremia and hyperkalemia do not result from an interaction with furosemide (Lasix) and digoxin (Lanoxin), so it will not increase the patient's risk for digoxin (Lanoxin) toxicity.


Rationale 3: Hypokalemia and hypocalcemia can result from an interaction with furosemide (Lasix) and digoxin (Lanoxin), so it will increase a patient's risk for digoxin (Lanoxin) toxicity. Hypercalcemia and hyperkalemia do not result from an interaction with furosemide (Lasix) and digoxin (Lanoxin), so it will not increase the patient's risk for digoxin (Lanoxin) toxicity. Hypermagnesemia and hyponatremia do not result from an interaction with furosemide (Lasix) and digoxin (Lanoxin), so it will not increase the patient's risk for digoxin (Lanoxin) toxicity. Hyponatremia and hyperkalemia do not result from an interaction with furosemide (Lasix) and digoxin (Lanoxin), so it will not increase the patient's risk for digoxin (Lanoxin) toxicity.Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.


Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 26-5


The patient receives captopril (Capoten) as treatment for heart failure. Which adverse effect will the nurse plan to report to the physician?

1. The patient develops a cough.

2. The patient develops diarrhea.

3. The patient develops dehydration.

4. The patient develops facial flushing.

Correct Answer: 1

Rationale 1: A cough is an adverse effect of captopril (Capoten) and should be reported to the physician. Diarrhea is not an adverse effect of captopril (Capoten). Facial flushing is not an adverse effect of captopril (Capoten). Dehydration is not an adverse effect of captopril (Capoten).



Rationale 4: A cough is an adverse effect of captopril (Capoten) and should be reported to the physician. Diarrhea is not an adverse effect of captopril (Capoten). Facial flushing is not an adverse effect of captopril (Capoten). Dehydration is not an adverse effect of captopril (Capoten).Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 26-5


The patient receives enalapril (Vasotec) as treatment for heart failure. What is the best nursing assessment following the initial administration of this drug?

1. Assess the patient for ototoxicity.

2. Assess the patient's blood pressure.

3. Assess the patient for an irregular pulse.

4. Assess the patient for a serious rash.

Correct Answer: 2

Rationale 1: Severe hypotension, known as first-dose phenomenon, can occur after the initial administration of enalapril (Vasotec). Ototoxicity is an adverse effect of loop diuretics. Stevens–Johnson syndrome is an adverse effect of beta blockers. Irregular pulse is an adverse effect of beta blockers.




Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment


Learning Outcome: 26-7


The patient takes insulin for diabetes mellitus. The physician orders metoprolol (Lopressor) for hypertension. After medication teaching, the nurse determines that learning has occurred when the patient makes which statement?

1. "I might not need to check my blood sugars as often with metoprolol (Lopressor)."

2. "I might be able to change from insulin to a pill with metoprolol (Lopressor)."

3. "I might need less insulin when I take metoprolol (Lopressor)."

4. "I might need more insulin when I take metoprolol (Lopressor)."

Correct Answer: 3

Rationale 1: Metoprolol (Lopressor) may enhance the hypoglycemic effects of insulin and oral hypoglycemic agents, so the patient might require less insulin. Metoprolol (Lopressor) may enhance the hypoglycemic effects of insulin and oral hypoglycemic agents, so the patient might require less, not more, insulin. Metoprolol (Lopressor) will not change a diabetic patient's need for insulin; the patient might just require less insulin. The patient will most likely need more frequent blood glucose assessments, as metoprolol (Lopressor) may enhance the hypoglycemic effects of insulin.





Global Rationale:



The patient has heart failure and receives digoxin (Lanoxin). Prior to discharge, what will the best teaching plan by the nurse include?

1. "Report a weight gain of 2 or more pounds per day."

2. "Report mental changes such as euphoria."

3. "Stop the medication if your pulse is 56."

4. "If you miss a dose, take two doses."

Correct Answer: 1

Rationale 1: Weight gain could indicate fluid retention and a worsening of heart failure. Patients should not take a double dose; this is considered an overdose that could lead to toxicity. If the pulse is 56, the patient should notify the physician, and not stop the medication unless directed to do so. Mental depression is more likely to occur than euphoria.




Global Rationale:

Cognitive Level: AnalyzingAdams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

Client Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 26-5


The patient has a history of cardiac disease and receives digoxin (Lanoxin). The nurse determines that education about dietary needs with this medication has been effective when the patient makes which selection for lunch?

1. Cottage cheese, peach salad, and blueberry pie

2. Baked fish, sweet potatoes, and banana pudding

3. Green bean soup, whole-wheat bread, and an apple

4. Hamburger, French fries, and chocolate chip cookies

Correct Answer: 2

Rationale 1: Fish, sweet potatoes, and bananas are high in potassium, which will help prevent digoxin toxicity. The hamburger is high in potassium, but the French fries are not appropriate for a cardiac patient. Green bean soup, whole-wheat bread, and an apple are not significant sources of potassium needed to help prevent digoxin toxicity. Cottage cheese,peach salad, and blueberry pie are not significant sources of potassium needed to help prevent digoxin toxicity.

Rationale 2: Fish, sweet potatoes, and bananas are high in potassium, which will help prevent digoxin toxicity. The hamburger is high in potassium, but the French fries are not appropriate for a cardiac patient. Green bean soup, whole-wheat bread, and an apple are not significant sources of potassium needed to help prevent digoxin toxicity. Cottage cheese, peach salad, and blueberry pie are not significant sources of potassium needed to help prevent digoxin toxicity.

Rationale 3: Fish, sweet potatoes, and bananas are high in potassium, which will help prevent digoxin toxicity. The hamburger is high in potassium, but the French fries are not appropriate for a cardiac patient. Green bean soup, whole-wheat bread, and an apple are not significant sources of potassium needed to help prevent digoxin toxicity. Cottage cheese, peach salad, and blueberry pie are not significant sources of potassium needed to help prevent digoxin toxicity.

Rationale 4: Fish, sweet potatoes, and bananas are high in potassium, which will help prevent digoxin toxicity. The hamburger is high in potassium, but the French fries are not appropriate for a cardiac patient. Green bean soup, whole-wheat bread, and an apple are not significant sources of potassium needed to help prevent digoxin toxicity. Cottage cheese,peach salad, and blueberry pie are not significant sources of potassium needed to help prevent digoxin toxicity.

Global Rationale:




Which individual listed below would be at the greatest risk for developing heart disease?

1. 35-year-old with diabetes mellitus and prehypertension

2. 75-year-old with Parkinson’s disease and normal blood pressure

3. 52-year-old with osteoporosis and stage 1 hypertension

4. 68-year-old with stage 2 hypertension and recent myocardial infarction

Correct Answer: 4

Rationale 1: Cardiac tissue weakens as people age, and can be caused or accelerated by chronic hypertension, myocardial infarction, diabetes mellitus, and other cardiac-related diseases. The 68-year-old patient has the most risk factors for developing heart failure. (p. 325)




Global Rationale:

Cognitive Level: UnderstandingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 26-1

Question 16


Type: MCSA

Which statement is accurate regarding the physiological changes associated with heart failure?

1. Blood backs up into the lungs due to right ventricular hypertrophy.

2. The walls of the heart shrink, leading to lower cardiac output.

3. Cardiac remodeling occurs after prolonged ventricular hypertrophy.

4. Blood pressure increases, resulting in lowered afterload.

Correct Answer: 3

Rationale 1: Heart walls thicken and enlarge with heart failure. These changes occur over time, and are referred to as cardiac remodeling. Blood can back up into the lungs, but this would be a result of left ventricular hypertrophy, not right. Blood pressure can go up, but would result in a higher, not lower, afterload.




Global Rationale:

Cognitive Level: UnderstandingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 26-2


Which of the following would lead to an increase in cardiac output?

1. Reduced cardiac contractility

2. Hypovolemia


3. Peripheral vascular resistance

4. Increase in preload

Correct Answer: 4

Rationale 1: Increased preload results in a more forceful contraction, and increases cardiac output. Hypovolemia is a lower blood volume, and will result in lower cardiac output. Peripheral vascular resistance increases afterload and increases the workload on the heart. A reduction in cardiac contractility results in lower preload and subsequent cardiac output.




Global Rationale:

Cognitive Level: UnderstandingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 26-3


Which of the following medications would be of most help to increase myocardial contractility in a patient with heart failure?

1. Digoxin (Lanoxin)

2. Lisinopril (Prinivil)

3. Carvedilol (Coreg)

4. Furosemide (Lasix)Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

Correct Answer: 1

Rationale 1: Cardiac glycosides increase cardiac output by increasing the force of contraction. Diuretics lower blood volume, beta blockers lower heart rate, and ACE inhibitors lower peripheral vascular resistance and blood volume.




Global Rationale:

Cognitive Level: RememberingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 26-5


Lisinopril (Prinivil) is often used to treat heart failure because it lowers blood volume. Which of the following best explains how lisinopril lowers blood volume?

1. It has an antagonistic effect on angiotensin-converting enzyme.

2. It lowers aldosterone secretion, a hormone that increases sodium reabsorption.

3. It causes hypernatremia and increased renal tubule permeability, resulting in a diuretic effect.

4. It causes a diuretic effect by lowering the amount of sodium lost in the urine.

Correct Answer: 2

Rationale 1: ACE inhibitors lower blood volume by lowering the secretion of aldosterone from the adrenal cortex. Aldosterone is a hormone that increases the reabsorption of sodium and water. ACE inhibitors have an antagonistic effect on angiotensin-converting enzyme, but this action lowers blood pressure by reducing peripheral vascular resistance, not by lowering blood volume. Increasing sodium in the blood will not lower blood volume. Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/ECopyright 2014 by Pearson Education, Inc.

Rationale 2: ACE inhibitors lower blood volume by lowering the secretion of aldosterone from the adrenal cortex. Aldosterone is a hormone that increases the reabsorption of sodium and water. ACE inhibitors have an antagonistic effect on angiotensin-converting enzyme, but this action lowers blood pressure by reducing peripheral vascular resistance, not by lowering blood volume. Increasing sodium in the blood will not lower blood volume.



Global Rationale:

Cognitive Level: UnderstandingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 26-5


Which statement is accurate regarding the use of beta-adrenergic blockers for use in patients with heart failure?

1. Higher doses are used initially until optimal vital signs are achieved.

2. Dosage changes are done on a daily basis for the first 2 weeks.

3. This drug class does not have an effect on the bronchioles of the lungs.

4. They are generally used in combination with other heart-failure drugs.

Correct Answer: 4

Rationale 1: Beta-adrenergic blockers are rarely used to treat heart failure alone. They are commonly used in combination with ACE inhibitors. Initial doses are small, and are doubled every 2 weeks until the optimal dose is achieved. Beta-adrenergic blockers can be selective to beta1 receptors or non-selective. Non-selective blockers block beta1 and beta2 receptors. The blockage of beta2 receptors can affect the bronchioles of the lungs.





Global Rationale:

Cognitive Level: UnderstandingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 26-5


Which vital sign is of greatest concern to the nurse prior to administering digoxin (Lanoxin)?

1. Heart rate

2. Temperature

3. Blood pressure

4. Respiratory rate

Correct Answer: 1

Rationale 1: An apical pulse should be checked for one full minute prior to administering digoxin. If the heart rate is low (generally 60 bpm), the medication should be held and the ordering practitioner informed. Digoxin can suppress electrical activity within the heart and lower heart rate.





Global Rationale:

Cognitive Level: RememberingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 26-5


Which of the following is the most serious adverse effect associated with milrinone (Primacor)?

1. Ventricular dysrhythmia

2. Nausea

3. Headache

4. Atrial dysrhythmia

Correct Answer: 1

Rationale 1: Milrinone is a phosphodiesterase inhibitor that can cause ventricular dysrhythmias. Atrial dysrhythmias can occur, but ventricular dysrhythmias are more serious. Headache and nausea also can occur, but are not as serious as ventricular dysrhythmias.





Global Rationale:

Cognitive Level: RememberingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 26-5


The nurse is concerned that a patient is developing right heart failure. What did the nurse assess in this patient?



1. Ankle edema

2. Enlarged liver

3. Displaced apical heart rate

4. Shortness of breath

5. Cough


Rationale 1: In right heart failure, the blood backs up into veins, resulting in peripheral edema.

Rationale 2: In right heart failure, the blood backs up into veins, resulting in engorgement of organs such as the liver.

Rationale 3: A displaced apical heart rate would indicate cardiac hypertrophy which is associated with right heart failure.

Rationale 4: Shortness of breath is a manifestation of left heart failure.

Rationale 5: A cough is a manifestation of left heart failure.

Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological Adaptation


Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 26-2


The nurse is caring for a patient who has been diagnosed with heart failure. The nurse knows that which conditions may have contributed to the development of heart failure in this patient?



1. Uncontrolled hypertension

2. Coronary artery disease

3. Diabetes

4. HIV

5. Mitral stenosis

Correct Answer: 1,2,3,5

Rationale 1: Uncontrolled hypertension is associated with the development of heart failure.

Rationale 2: Coronary artery disease is associated with the development of heart failure.

Rationale 3: Diabetes is associated with the development of heart failure.

Rationale 4: HIV is not associated with the development of heart failure.

Rationale 5: Mitral stenosis is associated with the development of heart failure.

Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 26-1



The nurse is educating a patient diagnosed with heart failure (HF). The nurse knows that instruction regarding compensatory mechanisms has been effective when the patient states,



1. "My heart enlarged in order to compensate for the effects of heart failure."

2. "My nervous system kicks in to compensate for the effects of heart failure."

3. "My body will decrease blood flow to other organs in order to compensate for heart failure."

4. "My body will increase urine output in order to compensate for the effects of heart failure."

5. "My body will produce anti-inflammatory agents to compensate for heart failure."


Rationale 1: Ventricular hypertrophy occurs as a compensatory mechanism to heart failure.

Rationale 2: One of the fastest homeostatic responses to diminished cardiac output is activation of the sympathetic nervous system (SNS). The increased heart rate resulting from sympathetic activation is a normal compensatory mechanism that serves to increase cardiac output.

Rationale 3: When cardiac output in a patient with HF is diminished, blood flow to the kidneys is reduced.

Rationale 4: Vasopressin (antidiuretic hormone), which is elevated in HF patients, causes fluid retention and worsens this condition.

Rationale 5: Two pro-inflammatory substances, tumor necrosis factor (TNF) and interleukin, are found in high levels in patients with HF and are associated with a poor prognosis.

Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Reduction of Risk PotentialNursing/Integrated Concepts: Nursing Process: EvaluationLearning Outcome: 26-3


The nurse is caring for a patient with heart failure. Which assessment findings indicate the patient is currently experiencing class 2 heart failure?




1. Fatigue with physical activity

2. Palpitations with physical activity

3. No symptoms with physical activity

4. Dyspnea with physical activity

5. Angina at rest


Rationale 1: Patients experiencing class 2 heart failure often experience fatigue.

Rationale 2: Patients experiencing class 2 heart failure often experience palpitations.

Rationale 3: Patients experiencing no symptoms with physical activity are classified as having class 1 heart failure.

Rationale 4: Patients experiencing class 2 heart failure often experience dyspnea.

Rationale 5: Patients experiencing class 4 heart failure are unable to perform physical activity and have symptoms at rest.

Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 26-4


The nurse is caring for a patient who is being treated pharmacologically for the symptoms of heart failure. What would be included in the nurse's role of pharmacologic management of this patient?




1. Teaching the patient how to space medications to decrease adverse effects

2. Teaching the patient the long-term benefits of beta blockers

3. Continually monitoring the patient during IV infusions

4. Decreasing medication dosages when the patient complains of adverse effects

5. Changing a medication that is no longer working to decrease the patient's symptoms


Rationale 1: One role of the nurse is patient teaching. The nurse should teach the patient how to space medications to decrease the hypotensive effects that can occur during treatment for heart failure.

Rationale 2: Beta blockers can have many adverse effects that can affect adherence. The nurse should teach the patient the long-term benefits in order to increase medication adherence.

Rationale 3: Patients who are receiving medications used to treat heart failure by IV require continual monitoring by the nurse.

Rationale 4: The nurse cannot change a dose of a medication without a health care provider's order. This is outside the nurse's scope of practice.

Rationale 5: The nurse cannot prescribe medications; it is outside the nurse's scope of practice to change a medication with a health care provider's order.

Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 26-5


The nurse is caring for a patient being treated pharmacologically for heart failure. Which laboratory values is the nurse careful to monitor during treatment?



1. Potassium levels


2. BUN

3. Creatinine

4. Liver function tests

5. Serum drug levels

Correct Answer: 1,2,3,5

Rationale 1: It is important to monitor electrolyte levels, especially potassium, when a patient is being treated pharmacologically for heart failure.

Rationale 2: It is important to monitor renal function while a patient is being treated pharmacologically for heart failure.

Rationale 3: It is important to monitor renal function while a patient is being treated pharmacologically for heart failure.

Rationale 4: It is not necessary to monitor liver function while a patient is being treated pharmacologically for heart failure.

Rationale 5: It is important to monitor serum drug levels while a patient is being treated pharmacologically for heart failure.

Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Pharmacological and Parenteral TherapiesNursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 26-7


Adams4e Tif Ch26

Documents

Transcript of Adams4e Tif Ch26