Nursing Care of Patients With Heart Failure

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is collecting data from a patient who is receiving digoxin (Lanoxin), 0.125 mg daily. Which finding should indicate to the nurse that the patient is experiencing side effects of the medication?
a. Bradycardia
b. Constipation
c. Skin flushing
d. Muscle cramps
____ 2. A patient is taking bumetanide (Bumex). What is the most important for the nurse to monitor in this patient?
a. Skin turgor
b. Temperature
c. Sacral edema
d. Muscle weakness
____ 3. A patient is diagnosed with a heart problem that affects preload. How should the nurse describe preload to the patient?
a. Ejection of blood from ventricles
b. Degree of stretch in ventricles before systole
c. Degree of muscle stretch in atrium during diastole
d. Amount of force ventricles exert to open valves and eject blood
____ 4. The nurse provides morphine as prescribed to a patient experiencing anxiety, dyspnea, diaphoresis; retractions; pink, frothy sputum; blood pressure 174/86 mm Hg; pulse 116 beats/min; and respirations 32/min. Which finding should the nurse consider as desirable after receiving the morphine?
a. Lethargy
b. Reduced blood pressure
c. Slow, shallow respirations
d. Increased pulmonary pressures
____ 5. A patient who is to receive bumetanide (Bumex) in 1 hour has less ankle edema and neck vein distention than earlier. What action should the nurse take?
a. Hold the Bumex.
b. Give the Bumex early.
c. Notify the registered nurse (RN).
d. Give the scheduled Bumex.
____ 6. A patient is receiving digoxin (Lanoxin) daily. Which symptom should the nurse report for follow-up related to the digoxin?
a. Anorexia
b. Constipation
c. Skin flushing
d. BP 118/68 mm Hg
____ 7. A patient with heart failure is prescribed bedrest however becomes angry and walks to the bathroom independently to use the commode. How should the nurse handle this situation?
a. Obtain a bedside commode.
b. Walk the patient to the bathroom.
c. Obtain a bedpan for the patient to use.
d. Call for help while holding the patient in bed.
____ 8. A patient has been given bumetanide (Bumex) 3 mg intravenously. Which action should the nurse take after this medication is administered?
a. Monitor urine output.
b. Weigh the patient in 2 hours.
c. Listen to heart sounds for irregular heart rhythms.
d. Watch for leg cramps, and medicate if necessary.
____ 9. The nurse is collecting data from a patient who is in left-sided heart failure. Which finding should the nurse identify as being consistent with this diagnosis?
a. Dyspnea, cough
b. Hypokalemia, edema
c. Edema, distended neck veins
d. Enlarged liver, distended neck veins
____ 10. The nurse is contributing to a plan of care for a patient who has heart failure. What should be the major goal of nursing management for this patient?
a. Increase fluid intake.
b. Reduce the workload of the heart.
c. Increase venous return to the heart.
d. Promote a decrease in cardiac output.
____ 11. The nurse is assisting with the care of a patient who is experiencing pulmonary edema. Which finding should the nurse expect to observe?
a. Pedal edema
b. Sacral edema
c. Nausea/vomiting
d. Pink, frothy sputum
____ 12. A patient with increased dyspnea has bilateral crackles on auscultation. Which action should the nurse take?
a. Notify the RN.
b. Help the patient lie on the right side.
c. Raise the head of the bed to 90 degrees.
d. Teach the patient how to use oral suctioning.
____ 13. The nurse is contributing to a plan of care for a patient who has had a 5 pound weight gain in 2 days, pitting edema of the ankles, lung crackles, and distended neck veins. Which nursing diagnosis would be given priority in the plan of care?
a. Noncompliance
b. Urinary Retention
c. Excess Fluid Volume
d. Ineffective Health Maintenance
____ 14. A patient with heart failure has clavicle muscle retractions, nostril flaring, and labored breathing. Vital signs are: blood pressure 162/84 mm Hg, pulse 120 beats/min, and respirations 32/min. Which patient data requires immediate action?
a. Quiet, shallow respirations
b. Jaw jutting forward to inhale
c. Leaning on the over-bed table
d. Use of neck accessory muscles
____ 15. During a visit to the home of a patient with heart failure and diabetes the nurse learns that the patient “feels strange.” Data collected includes blood pressure 172/94 mm Hg, pulse 112 beats/min, respirations 22/min; heart rhythm regular; coarse crackles in lower lung bases. What action should the nurse take?
a. Consult the RN.
b. Give the patient orange juice.
c. Assist patient to bed for a nap.
d. Recheck vital signs in 30 minutes.
____ 16. The nurse is caring for a patient who is prescribed furosemide (Lasix). Which laboratory result should the nurse review first?
a. Urine sodium
b. Serum sodium
c. Urine potassium
d. Serum potassium
____ 17. A patient with a potassium level of 3 mEq/L is to receive furosemide (Lasix) 20 mg by mouth. What action should the nurse take?
a. Give the Lasix 30 minutes early.
b. Give the Lasix as scheduled now.
c. Consult the RN before giving Lasix.
d. Hold this scheduled dose of the Lasix.
____ 18. A patient is receiving potassium (K-Lor) 10 mEq/L, bumetanide (Bumex) 20 mg, and digoxin (Lanoxin) 0.125 mg orally. The patient’s morning potassium level is 4.2 mEq/L and the dose of K-Lor 10 mEq/L is scheduled to be given now. What action should the nurse take?
a. Hold K-Lor.
b. Inform the RN.
c. Hold the next dose of digoxin.
d. Give K-Lor as scheduled now.
____ 19. A patient is receiving potassium (K-Lor) 20 mEq/L, furosemide (Lasix) 20 mg, and digoxin (Lanoxin) 0.125 mg orally. The patient’s potassium level is 5.8 mEq/L and the dose of K-Lor 10 mEq/L is scheduled to be given now. What action should the nurse take?
a. Monitor the urine output.
b. Give K-Lor as scheduled now.
c. Assess the patient’s pulse rate.
d. Hold the scheduled dose of Lasix.
____ 20. A patient is receiving potassium (K-Lor) 20 mEq/L, furosemide (Lasix) 20 mg, and digoxin (Lanoxin) 0.125 mg orally. The patient’s potassium level is 4 mEq/L and urine output for the last 8 hours was 350 mL. What should the nurse do about the prescribed medications?
a. Inform the RN.
b. Hold the scheduled dose of Lasix.
c. Give medications as scheduled now.
d. Hold the scheduled dose of Lanoxin.
____ 21. The nurse is reinforcing discharge teaching provided to a patient taking antirejection medication following a heart transplant. Which beverage should the nurse instruct the patient to avoid?
a. Milk
b. Tomato juice
c. Cranberry juice
d. Grapefruit juice
____ 22. A patient recovering from heart transplant surgery is shivering, has weak peripheral pulses, mottled skin on the feet, and excessive chest tube drainage. Which nursing diagnosis should the nurse recommend?
a. Pain related to sternotomy and incisions
b. Decreased Cardiac Output due to hypovolemia
c. Risk for Impaired Skin/Tissue Integrity due to incision
d. Risk for Infection due to inadequate primary defenses from surgical wound and immunosuppression
____ 23. The nurse is reinforcing discharge teaching provided to a patient with a history of right-sided heart failure. What should the nurse include?
a. “You should increase the amount of iron in your diet.”
b. “Watch for diarrhea, as it is a symptom of increased failure.”
c. “Part of your heart tissue has died, so you will need to get plenty of rest.”
d. “It is important for you to weigh yourself daily and call the doctor if you gain more than 2 pounds in 1 day.”
____ 24. A patient reports shortness of breath after lying down, which caused a feeling of suffocation. How should the nurse document this finding?
a. Orthopnea
b. Exertional dyspnea
c. Activity-induced dyspnea
d. Paroxysmal nocturnal dyspnea
____ 25. During a home visit, the nurse learns that a patient with chronic heart failure is planning to quit cardiac rehabilitation because of the fear of dying while on the treadmill. Which response by the nurse is best?
a. “I don’t blame you for feeling frustrated, I hate to exercise too.”
b. “People don’t die on the treadmill; it’s to make your heart stronger.”
c. “It sounds like you want to give up. I’ll call the doctor and have you transferred to the hospice program.”
d. “You sound upset. Did you know research shows that cardiac rehab programs give people better medical outcomes and a higher quality of life?”
____ 26. The nurse is reinforcing teaching provided to a patient with chronic heart failure who is scheduled for pacemaker placement. Which patient statement indicates that additional instruction is required?
a. “I need to have this surgery to reduce the risk of sudden death.”
b. “I won’t have to take my cardiac medications after the surgery.”
c. “The pacemaker helps treat my heart failure by making my heart pump regularly.”
d. “The pacemaker will help keep a steady rhythm so blood is pumped more efficiently.”
____ 27. The nurse is teaching a patient with heart failure how to avoid activity that results in Valsalva’s maneuver. Which observation indicates that teaching has been effective?
a. The patient takes shallow breaths.
b. The patient uses a straw when drinking.
c. The patient strains while using the commode.
d. The patient breathes normally when sitting up.
____ 28. A patient requiring oxygen therapy is being discharged home. At which flow rate should the nurse instruct the patient to keep the oxygen level?
a. 1 liter
b. 2 to 6 liters
c. 8 liters
d. 10 liters
____ 29. The nurse is monitoring the chest tube drainage for a patient recovering from cardiac surgery. What volume should the nurse report to the charge nurse?
a. 50 mL/hr
b. 100 mL/hr
c. 150 mL/hr
d. 225 mL/hr
____ 30. A patient diagnosed with complete right-sided heart failure. For which additional health problem should the nurse collect data on this patient?
a. Dissecting aorta
b. Cor pulmonale
c. Carotid artery stenosis
d. Abdominal aortic aneurysm
____ 31. A patient with lower extremity edema from heart failure is fatigued from constant sleep interruption to void. What should the nurse instruct the patient to promote uninterrupted rest?
a. Take prescribed diuretics immediately before going to bed
b. Recline with the legs below heart level for 1 hour before going to bed
c. Sit with the legs crossed at the ankles for 1 to 2 hours before going to bed
d. Recline with the legs above heart level for 30 minutes before going to bed
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 32. As part of discharge teaching, the nurse is instructing a patient on the use of digoxin. What should be included in the teaching? (Select all that apply.)
a. Report if a persistent cough occurs.
b. Change position quickly to avoid orthostatic hypotension.
c. Take medication exactly as directed at the same time each day.
d. Report blurred vision, photophobia, or seeing yellowish green halos.
e. Take pulse before taking medication and if below 60 or above 100, call the physician.
____ 33. The nurse is reinforcing teaching provided to a patient prescribed captopril (Capoten). What should the nurse specifically include in instructions? (Select all that apply.)
a. Take medication with meals.
b. Report any cough that develops.
c. Use sunscreen to prevent photosensitivity.
d. Check blood pressure weekly and report changes.
e. Report to the laboratory weekly for laboratory follow-up.
f. Report any swelling of the hands, feet, or tongue or difficulty swallowing.
____ 34. The nurse reinforced teaching for a patient awaiting a heart transplant. Which statements indicate that the patient understands the usual criteria used for a potential heart donor? (Select all that apply.)
a. Age less than 55 years
b. No hypertension or diabetes
c. Absence of malignant disease
d. Presence of no active infections
e. Presence of no significant cardiac disease
f. Weight within 35 lb of prospective recipient
____ 35. The nurse is reviewing compensatory mechanisms with a patient in heart failure. What should the nurse include when providing this teraching? (Select all that apply.)
a. Urine output increases.
b. Muscle mass of the heart decreases.
c. Oxygen demand of the heart is lowered.
d. Epinephrine and norepinephrine are released.
e. Kidneys activate the renin-angiotensin-aldosterone system.
f. Heart muscles stretch to increase the force of myocardial contraction.
____ 36. A patient with heart failure is prescribed an angiotensin-converting enzyme inhibitor (ACEI). What should the nurse teach the patient about this medication? (Select all that apply.)
a. Prevents remodeling
b. Reduces fluid volume
c. Lowers blood pressure
d. Reduces workload on the heart
e. Decrease pulmonary venous pressure
____ 37. While collecting data, the nurse suspects that a patient is demonstrating signs of heart failure. What findings did the nurse use to come to this conclusion? (Select all that apply.)
a. Hunger
b. Fatigue
c. Dry cough
d. Ankle edema
e. Shortness of breath when lying down
Completion
Complete each statement.

38. The health care provider (HCP) wants to be notified if a patient recovering from a heart transplant has a urine output less than 0.5 mL/kg/hour. The patient weighs 176 lbs. What is the amount of urine the patient has to produce before the HCP is notified?

Chapter 26. Nursing Care of Patients With Heart Failure
Answer Section

MULTIPLE CHOICE

1. ANS: A
Bradycardia is an adverse effect of digoxin. The apical pulse is taken for 1 minute prior to administration. B. C. D. These are not adverse effects of digoxin.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

2. ANS: D
Hypokalemia can occur with bumetanide (potassium-wasting diuretic), which is why potassium levels are monitored before administration of the medication. Mild hypokalemia is often asymptomatic but can cause a rise in blood pressure or cardiac dysrhythmias. Moderate hypokalemia can cause muscle weakness, muscle cramping, and constipation. A. A change in skin turgor could indicate dehydration however this is not the most important for the nurse to monitor in this patient. B. C. These findings do not indicate an adverse effect of the medication.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

3. ANS: B
The fluid volume returning to the heart (preload) causes stretch in ventricles before systole. The more fluid there is, the greater the stretch can be. A. C. D. These statements do not describe preload.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

4. ANS: B
Morphine reduces preload, afterload, and anxiety. Reduced blood pressure reflects a desired effect of the morphine. A. C. D. These are undesired effects from the morphine.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

5. ANS: D
The nurse should give the medication as prescribed since the desired effect is to reduce ankle edema and prevent it from occurring. A. B. C. There is no reason to hold the medication, give it early, or to notify the RN.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

6. ANS: A
Anorexia is a symptom of digoxin toxicity. A digoxin level should be done and digoxin held until the results are reviewed by the physician. B. C. D. These findings do not indicate digoxin toxicity.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

7. ANS: A
A bedside commode can ensure for the patient’s safety, puts less strain on the heart than using a bedpan, and maintains the bedrest order B. This action would not support the order for bedrest. C. A bedpan puts strain on the heart. D. The nurse cannot restrain the patient in bed.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Analysis

8. ANS: A
Bumetanide (Bumex) is a diuretic; the nurse should monitor urine output. B. The patient’s weight is not going to reflect the effects of the medication within 2 hours. C. This medication does not cause cardiac dysrhythmias. D. Leg cramps should be reported.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

9. ANS: A
Left-sided heart failure symptoms include lung symptoms such as dyspnea and cough. B. C. D. These findings are more common with right-sided heart failure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

10. ANS: B
Reducing the workload of the heart is the major goal for the patient with heart failure. A. Fluid overload is a manifestation of heart failure. C. Venous return needs to be promoted. D. A decrease in cardiac output would increase the patient’s symptoms.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

11. ANS: D
Pink, frothy sputum is the classic symptom of pulmonary edema. A. B. C. These are systemic symptoms of heart failure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

12. ANS: C
High Fowler’s position aids breathing as the lungs can more easily expand the higher upright the patient sits. A. Placing the patient in an optimal position would be the first priority. Then the RN should be notified. B. Lying on the right side will not improve oxygenation. D. The patient does not need to be instructed on the use of oral suctioning.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

13. ANS: C
The manifestations observed indicate excess fluid volume. A. B. D. The manifestations do not support noncompliance, urinary retention, or ineffective health maintenance.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

14. ANS: A
As the body is less able to compensate for decreased cardiac output, respirations will slow and become shallow. This patient is in serious difficulty and would need immediate treatment to survive. B. C. D. These are signs of the body working to compensate and provide more oxygen.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

15. ANS: A
The RN or supervisor should be consulted immediately so that the patient’s symptoms of heart failure which could progress to pulmonary edema can be treated. The physician will then be contacted for treatment orders. B. There is no evidence that orange juice is needed. C. D. There is no evidence that the patient is fatigued and waiting to reassess vital signs in 30 minutes could be dangerous for the patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

16. ANS: D
Furosemide (Lasix) is a potassium-wasting diuretic. It is essential to monitor and review potassium levels before administering the Lasix, and if the level is too low, it should be held and the RN or physician notified. A. B. It is not necessary to review urine or serum sodium levels. C. A urine potassium level might not be available.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

17. ANS: C
Furosemide (Lasix) is a potassium-wasting diuretic. The potassium level is low, so the Lasix should not be given, and the RN or physician should be notified of the potassium level for further orders. A. B. D. These actions should not be done before consulting with the RN.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

18. ANS: D
The nurse should give the K-Lor as scheduled now. The patient is on a potassium-wasting diuretic, Bumex, but the potassium level is within normal limits due to the potassium supplement, so it is important to continue to give the K-Lor now. A. There is no reason to hold the K-Lor. B. There is nothing significant to report to the RN. C. There is no evidence to support holding the next dose of digoxin.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

19. ANS: D
The nurse should not give the K-Lor as the potassium is too high and giving more could have serious effects for the patient. The assessments listed do not clarify the patient’s condition or address hyperkalemia. A. C. These actions do not support the patient’s elevated potassium level. B. Giving the dose of potassium could be harmful and lead to adverse effects in the patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

20. ANS: C
The nurse should give the medications as scheduled now. The patient has some urine output but needs the medications to increase it. The patient needs the diuretic to remove fluid and the potassium to balance potassium loss. The digoxin will help improve cardiac output by strengthening heart contractions. A. There is no reason to inform the RN. B. D. There is no reason to hold the Lasix or Lanoxin.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

21. ANS: D
Grapefruit juice may cause elevated levels of the drug and should not be taken. A. B. C. There is no reason for the patient to avoid drinking milk, tomato juice, or cranberry juice.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

22. ANS: B
The patient is losing fluid volume through the chest tube and is at risk for hypovolemia and decreased cardiac output. A. C. D. These diagnoses do not address all of the patient’s symptoms at this time.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

23. ANS: D
Right-sided heart failure has symptoms of systemic fluid overload, including weight gain, hepatomegaly, splenomegaly, ascites, and nausea. C. Cardiac ischemia occurs with a myocardial infarction (MI), not with right-sided heart failure. A. Increased iron consumption in the diet is suggested for iron-deficiency anemia. B. Diarrhea is not a symptom of right-sided failure.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

24. ANS: D
Paroxysmal nocturnal dyspnea is sudden shortness of breath after lying flat for a time, due to excess fluid accumulation in the lungs from fluid returning to the heart after gravity affects are released from the legs. The sleeping person awakens with feelings of suffocation. Relief is obtained by sitting upright for a short time. A. B. C. These terms do not describe the patient’s symptoms.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

25. ANS: D
Cardiac rehabilitation programs for patients with chronic heart failure have been shown to improve quality of life. In a randomized controlled study of 123 medically stable heart failure patients over 10 years, exercise training demonstrated improved functional capacity and quality of life over patients who did not exercise regularly A. B. C. Therapeutic responses should focus on the patient, use open-ended statements, and provide education when possible.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

26. ANS: B
The patient will still need to take other cardiac medications. A. C. D. For patients at risk of sudden death, pacemakers and implantable cardioverter defibrillators (ICDs) are used along with medication therapy. They can pace the heart or deliver an electric counter-shock if a life-threatening rhythm occurs.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

27. ANS: D
Valsalva’s maneuver occurs when the breath is held or one bears down. By breathing normally, Valsalva’s maneuver is avoided, which reduces strain on the heart. A. B. C. These actions can potentiate the use of the Valsalva maneuver.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

28. ANS: B
For chronic heart failure, oxygen is administered at 2 to 6 L/min via nasal cannula. A. One liter is not sufficient for this patient. C. D. This is too much oxygen for the patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive Level: Application

29. ANS: D
In a patient who has had cardiac surgery, chest tube drainage greater than 200 mL/hour may lead to hypovolemia and a decrease in cardiac output. A. B. C. These volumes of drainage do not need to be reported to the charge nurse.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

30. ANS: B
When the right ventricle hypertrophies or fails because of increased pulmonary pressures, it is referred to as cor pulmonale. A. C. D. These health problems are not related to right-sided heart failure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

31. ANS: D
Patients will often void shortly after going to bed due to fluid in the legs returning to the heart and then the kidneys for filtering after they lie down. To help patients get as much undisturbed rest as possible, teach them to recline with their legs at or above heart level for at least 30 minutes before going to bed. Then they can void before going to bed, instead of soon after. A. B. C. These actions will cause the patient to have to get up to void frequently after going to bed.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

MULTIPLE RESPONSE

32. ANS: C, D, E
Pulse rate should be taken and vision changes reported, as they indicate toxicity, and medication should be taken as directed. B. Orthostatic hypotension is a concern with medications that affect blood pressure, not digoxin. A. A persistent cough occurs with angiotensin converting enzyme inhibitor (ACEI) medications.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

33. ANS: B, D, F
The patient should check blood pressure weekly; report cough, swelling of the hands, feet, or tongue, or difficulty swallowing. A. It is not necessary to take the medication with meals. C. Photosensitivity is not an issue. E. Weekly laboratory tests are not necessary.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

34. ANS: B, C, D, E
Donors should not have infections, significant cardiac or malignant disease, hypertension, or diabetes. A. F. Donors should be younger than 45 years and donor body weight should be no greater than 30% below the recipient’s weight.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

35. ANS: D, E, F
Epinephrine and norepinephrine are released, the renin-angiotensin-aldosterone system is activated, and heart muscles stretch. A. B. C. Muscle mass of the heart increases, urine output decreases, and the oxygen demand of the heart is increased.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

36. ANS: A, C, D
ACEIs are considered the first-choice drug over angiotensin receptor blockers (ARBs). They are used for their vasodilation effect, which lowers blood pressure and reduces workload on the heart. They also offer additional benefit by preventing remodeling, which is an effect that leads to progressive cardiac deterioration. B. E. Diuretics reduce fluid volume and decrease pulmonary venous pressure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

37. ANS: B, C, D, E
Manifestations of heart failure include fatigue, dry cough, ankle edema, and shortness of breath when lying down. A. Anorexia is a manifestation of heart failure and not hunger.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

COMPLETION

38. ANS:
40 mL
The patient’s weight in kg is 176 lbs/2.2 = 80 kg. If the patient needs to produce 0.5 mL of urine per hour per kg, then multiply the patient’s weight by the volume or 80 kg ´ 0.5 mL = 40 mL. The patient needs to produce 40 mL of urine per hour.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application