Chapter 35: Nursing Management: Heart Failure
Test Bank
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
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
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%?
Need to participate in an aerobic exercise program several times weekly
Use of salt substitutes to replace table salt when cooking and at the table
Importance of making a yearly appointment with the primary care provider
Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
a.
b.
c.
d.
ANS: D
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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
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
5. A patient who has 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 will document
this assessment information as
a. pulsus alternans.
b. two-pillow orthopnea.
c. acute bilateral pleural effusion.
d. paroxysmal nocturnal dyspnea.
ANS: D
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: Knowledge
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
6. During a visit to a 72-year-old with chronic heart failure, the home care nurse finds that the
patient has ankle edema, a 2-kg weight gain, and complains of “feeling too tired to do
anything.” Based on these data, the best nursing diagnosis for the patient is
a. activity intolerance related to fatigue.
b. disturbed body image related to leg swelling.
c. impaired skin integrity related to peripheral edema.
d. impaired gas exchange related to chronic heart failure.
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ANS: A
The patient’s 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.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
7. 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
uses an additional pillow to sleep when feeling short of breath at night.
tells the home care nurse that furosemide (Lasix) is taken daily at bedtime.
calls the clinic when the weight increases from 124 to 130 pounds in a week.
says that the nitroglycerin patch will be used for any chest pain that develops.
a.
b.
c.
d.
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 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. The patient should
call the clinic if increased orthopnea develops, rather than just compensating by elevating the
head of the bed further.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
8. When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains
that foods to be restricted include
canned and frozen fruits.
fresh or frozen vegetables.
milk, yogurt, and other milk products.
eggs and other high-cholesterol foods.
a.
b.
c.
d.
ANS: C
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.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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. avoid dietary sources of potassium.
b. take the hydrochlorothiazide before bedtime.
c. notify the health care provider about any nausea.
d. never take digoxin if the pulse is below 60 beats/minute.
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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.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
10. While admitting an 80-year-old with 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 patient’s discharge the nurse will facilitate
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.
ANS: B
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 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.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
11. Following an acute myocardial infarction, a previously healthy 67-year-old develops clinical
manifestations of heart failure. The nurse anticipates discharge teaching will include
information about
a. angiotensin-converting enzyme (ACE) inhibitors.
b. digitalis preparations.
c. -adrenergic agonists.
d. calcium channel blockers.
ANS: A
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.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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12. A 55-year-old 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 appropriate?
a. “Since you are diabetic, 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
considered.”
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, 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 patient’s question.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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 creatine kinase (CK)
b. Arterial blood gases (ABGs)
c. B-type natriuretic peptide (BNP)
d. 12-lead electrocardiogram (ECG)
ANS: C
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
also may be used in determining the causes or effects of heart failure but are not as clearly
diagnostic of heart failure as BNP.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. Which action will 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)?
Monitor blood pressure frequently.
Encourage patient to ambulate in room.
Titrate nesiritide rate slowly before discontinuing.
Teach patient about safe home use of the medication.
a.
b.
c.
d.
ANS: A
Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension.
Since 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.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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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 captopril, which statement by the
patient indicates that teaching has been effective?
a. “I will call for help when I need to get up to use the bathroom.”
b. “I will be sure to take the medication after eating something.”
c. “I will need to include more high-potassium foods in my diet.”
d. “I will expect to feel more short of breath for the next few days.”
ANS: A
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 sparing, 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.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
16. A patient who has just been admitted with pulmonary edema is scheduled to receive these
medications. Which medication should the nurse question?
furosemide (Lasix) 40 mg
captopril (Capoten) 25 mg
digoxin (Lanoxin) 0.125 mg
carvedilol (Coreg) 3.125 mg
a.
b.
c.
d.
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: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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 take first?
Palpate the abdomen.
Assess the orientation.
Check the capillary refill.
Auscultate the lung sounds.
a.
b.
c.
d.
ANS: D
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
also should be accomplished rapidly, but detection (and treatment) of pulmonary
complications is the priority.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
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18. A patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and
a low-sodium diet tells the home health nurse 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.
b. question 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 dietary sodium restrictions.
ANS: C
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, reinforcement of sodium restrictions, and assessment of medication
compliance may be appropriate interventions but are not the first nursing actions indicated.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
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 these medications have
been ordered for the patient. The first action by the nurse will be to
a. give IV diazepam (Valium) 2.5 mg.
b. administer IV morphine sulfate 2 mg.
c. increase nitroglycerin (Tridil) infusion by 5 mcg/min.
d. increase dopamine (Intropin) infusion by 2 mcg/kg/min.
ANS: B
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 also will 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: Analysis
TOP: Nursing Process: Implementation
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
20. After receiving change-of-shift report, which of these patients admitted with heart failure
should the nurse assess first?
a. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure (BP) of
100/56
b. A patient who is cool and clammy, with new-onset confusion and restlessness
c. A patient who had dizziness after receiving the first dose of captopril (Capoten)
d. A patient who has crackles in both posterior lung bases and is receiving oxygen
ANS: B
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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.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
21. Which assessment finding in a patient admitted with acute decompensated heart failure
(ADHF) requires the most rapid action by the nurse?
Oxygen saturation of 88%
Weight gain of 1 kg (2.2 lb)
Apical pulse rate of 106 beats/minute
Urine output of 50 mL over 2 hours
a.
b.
c.
d.
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 rapid nursing actions, but the low oxygen saturation rate requires the most immediate
nursing action.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
22. A patient has recently started taking oral digoxin (Lanoxin) in addition to furosemide (Lasix)
and captopril (Capoten) for control of heart failure. Which assessment finding by the home
health nurse is most important to communicate to the health care provider?
a. Presence of 1 to 2+ edema in the feet and ankles
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. 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 also 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.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
23. An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with
carvedilol (Coreg). Which of these assessment findings is most important for the nurse to
report to the health care provider?
a. Pulse rate of 56
b. 2+ pedal edema
c. BP of 88/42 mm Hg
d. Complaints of fatigue
ANS: C
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The patient’s BP indicates that the dose of carvedilol may need to be decreased because of
hypotension. Bradycardia is a frequent adverse effect of -adrenergic blockade, but the rate of
56 is not unusual with -blocker therapy. -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.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
24. A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated
heart failure (ADHF) has 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. Evaluate the IV insertion site for extravasation.
b. Monitor the patient’s BP and heart rate every hour.
c. Adjust the rate to keep the systolic BP >90 mm Hg.
d. Teach the patient the reasons for remaining on bed rest.
ANS: B
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.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
OBJ: Special Questions: Delegation
MSC: NCLEX: Safe and Effective Care Environment
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