Nursing Action and Heart Failure Management

Question 1

Scenario: 65-year-old patient with heart failure, SOB, weight gain, swollen ankles

• Correct Action: Assess lung sounds and signs of fluid overload
• Rationale: Initial assessment is crucial to determine severity; guides subsequent interventions.

Question 2

Scenario: Patient taking ACE inhibitor

• Incorrect Statement: Stop medication if dry cough develops
• Correct Answer: Inform healthcare provider
• Rationale: Patients shouldn't stop medication without consulting; need education on managing side effects.

Question 3

Scenario: Heart failure patient, lab results

• Critical Value: Potassium 3.0 mEq/L
• Rationale: Hypokalemia is dangerous, can lead to cardiac dysrhythmias; other values normal.

Question 4

Scenario: Energy conservation techniques in heart failure patient

• Incorrect Statement: Do all activities in the morning
• Correct Answer: Spread activities throughout the day
• Rationale: Pacing avoids excessive fatigue and symptom worsening.

Question 5

Scenario: Patient taking furosemide (loop diuretic)

• Important Symptom to Report: Muscle weakness or cramps
• Rationale: Indicates electrolyte imbalances (hypokalemia); awareness is crucial.
• Other Points: Nighttime dosage disrupts sleep; fluid intake limit too restrictive; weight gain not typical.

Question 6

Scenario: Heart failure patient assessment

• Critical Finding: Oxygen saturation 88% on room air
• Rationale: Indicates hypoxemia; requires immediate intervention.

Question 7

Scenario: Patient on digoxin

• Important Symptom to Report: Vision changes (yellow halos)
• Rationale: Sign of digoxin toxicity; other options not typically digoxin-related.

Question 8

Scenario: Preventing pulmonary complications

• Key Intervention: Oxygen therapy as prescribed
• Rationale: Improves oxygenation; lying flat worsens congestion; fluid restriction individualized; diuretics used for management.

Question 9

Scenario: Patient with bilateral pitting edema

• Appropriate Action: Elevate legs
• Rationale: Reduces edema and improves venous return; other actions not as appropriate.

Question 10

Scenario: Patient taking Lisinopril, persistent dry cough

• Best Response: Inform healthcare provider
• Rationale: Likely need medication change; stopping or increasing fluids not appropriate initial actions.

Question 11

Scenario: Discharge education on heart failure

• Incorrect Statement: Take extra diuretic if short of breath
• Correct Answer: Should not adjust medication without consulting provider
• Rationale: Self-adjusting can lead to imbalances, dehydration; other statements appropriate.

Question 12

Scenario: Acute decompensated heart failure

• Likely Observation: Pink frothy sputum
• Rationale: Indicates pulmonary edema; other symptoms not typical.

Question 13

Scenario: Patient prescribed beta blockers

• Primary Reason: Reduce workload on the heart
• Rationale: Decreases heart rate/contractility, improves output; not for renal function or fluid overload.

Question 14

Scenario: Dietary modifications education

• Food to Limit: Processed cheese
• Rationale: High sodium exacerbates fluid retention; fresh fruits, whole grains, and skinless chicken are healthier choices.

Question 15

Scenario: Priority assessment for heart failure patient

• Key Assessment: Daily weight
• Rationale: Rapid weight gain indicates fluid retention; other assessments important but secondary.

Question 16

Scenario: Self-management education

• Incorrect Statement: Elevate legs if swollen at night
• Correct Answer: Seek medical advice for worsening symptoms
• Rationale: Indicates decompensation; should report to healthcare provider.

Question 17

Scenario: Patient with high anxiety levels

• Appropriate Intervention: Encourage deep breathing/relaxation
• Rationale: Non-pharmacological interventions effective; anxiolytics not first-line.

Question 18

Scenario: Home visit, noted canned soups

• Nursing Action: Educate about high sodium content
• Rationale: Can exacerbate heart failure symptoms; patient needs education on low sodium diet.

Question 19

Scenario: Increasing nocturnal dyspnea

• Priority Action: Assess for other fluid overload symptoms
• Rationale: Signs of worsening heart failure; need assessment for appropriate intervention.

Question 20

Scenario: Effective understanding of medication management

• Correct Statement: Take medications as prescribed
• Rationale: Adherence crucial for management; other statements reflect misunderstandings.

Question 21

Scenario: Difficulty adhering to sodium-restricted diet

• Appropriate Response: Explore low sodium food options
• Rationale: Collaborative approach promotes adherence; positive and patient-centered.

Question 22

Scenario: Frequent nighttime urination

• Best Advice: Take diuretic in the morning
• Rationale: Reduces nocturia, improves sleep; should consult provider.

Question 23

Scenario: Non-adherence to exercise regimen

• Appropriate Action: Explore reasons/barriers
• Rationale: Understanding barriers allows tailored support; patient-centered approach more effective.

Question 24

Scenario: Early sign of worsening heart failure

• Key Indicator: Decreased urine output
• Rationale: Indicates reduced kidney perfusion; not typically sudden weight loss, increased tolerance, or appetite.

Question 25

Scenario: Self-monitoring for fluid overload

• Important Action: Check for pitting edema daily
• Rationale: Practical method for fluid overload monitoring; weights should be daily, fluid intake individualized.

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