Heart Failure Case Study (45 min)

Cardiac

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7 Heart Failure Case Study (45 min) NCLEX Questions

Question 1 of 7

The nurse is caring for a client with worsening congestive heart failure. Which of the following are expected findings in a client with this condition? Select all that apply.

Brain natriuretic peptide level of 90 pg/mL

Shortness of breath at rest

Warm, pink skin

Slow capillary refill

Tachycardia

Question 2 of 7

The nurse is caring for a client who was admitted with shortness of breath and has a new diagnosis of heart failure. Which of the following labs indicate that the client is suffering from severe heart failure?

BNP 850 pg/mL

LDL 192 mg/dL

LDL 19.2 mmHg

BNP 85 pg/mL

Question 3 of 7

The nurse caring for a newborn diagnosed with a ventricular septal defect knows that which of the following are common symptoms of heart failure in infants? Select all that apply

Periorbital edema

Weight gain

Sweating

Arthralgia

Gallop rhythm

Question 4 of 7

A nurse is providing instructions to a pregnant client who also has a diagnosis of heart failure. What should be included in those instructions?

Remain on bed rest

Report weight gain of 0.5 pounds in a week

Report decrease in fetal movement

Report swelling in ankles and feet

Question 5 of 7

The nurse is caring for a client with a history of congestive heart failure (CHF). While reviewing his medications with the nurse, the client asks for help identifying which medication is for CHF. The nurse knows that which of the following medication is used to treat this condition?

Cephalexin

Clopidogrel

Captopril

Cimetidine

Question 6 of 7

A nurse is caring for a client with heart failure. During the shift assessment the nurse notes that the client has pitting edema, shortness of breath, and which heart sound?

Clicking

Gallop

Swooshing

Rubbing

Question 7 of 7

The nurse is caring for a client with hypokalemia, heart failure, and 3+ pitting edema in the lower extremities. Which of the following medications would the nurse anticipate giving to this client?

Spironolactone

Bumetanide

Furosemide

HCTZ

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Outline

Mr. Jones, a 69-year old male, presents to the Emergency Department (ED) after visiting his primary physician complaining of general fatigue for 4 days, shortness of breath, and abdominal discomfort. Mr. Jones’s medical history includes hypertension and coronary artery disease. He had a previous 90% LAD blockage and 50% RCA blockage with stent placements in both.

Critical Thinking Check

Bloom's Taxonomy: Application

What initial nursing assessments need to be performed for Mr. Jones?

VIEW ANSWER

Full set vital signs
Heart sounds
Lung Sounds
Pulses
Edema
Skin condition (color, temperature, etc.)

Critical Thinking Check

Bloom's Taxonomy: Analysis

What diagnostic tests do you anticipate being ordered by the provider?

VIEW ANSWER

Chest X-ray

12-lead EKG

Echocardiogram

BNP

Cardiac Enzymes

Upon further assessment, the patient has crackles bilaterally and tachycardia. A chest X-ray shows cardiomegaly and bilateral pulmonary edema. An ECG revealed atrial fibrillation. His vital signs were as follows:

BP 150/72 mmHg Urine Yellow and Cloudy

HR 102-123 bpm and irregular BUN 17 mg/dL

RR 24-32 bpm Cr 1.2 mg/dL

Temp 37.3°C H/H 11.8 g/dL / 36.2%

Ht 175 cm LDH 705 U/L

Wt 79 kg ** BNP 843 pg/mL

Mr. Jones was admitted to the cardiac telemetry unit.

Mr. Jones states that this weight is approximately 3 kg more than it was 3 days ago.

Critical Thinking Check

Bloom's Taxonomy: Analysis

What is the significance of Mr. Jones' weight gain?

VIEW ANSWER

1 kg weight gain is equal to 1 liter of weight gain. This means Mr. Jones has gained 3 liters of fluid (as volume excess) in just 3 days.
This likely means that there is a new onset or exacerbation of heart failure

Critical Thinking Check

Bloom's Taxonomy: Analysis

What medications do you anticipate the provider ordering for Mr. Jones? Why?

VIEW ANSWER

Diuretics – he is volume overloaded and it is affected his lungs. Diuretics can help relieve fluid retention by promoting excretion of water from the kidneys.
Beta-Blockers – his blood pressure is high and his heart rate is fast. The beta-blocker can help slow this down and relieve some of the workload of his heart

About three hours after admission to the telemetry unit, Mr. Jones’s skin becomes cool and clammy. His respirations are labored and he is complaining of abdominal pain. Upon physical examination, Mr. Jones is diaphoretic and gasping for air, with jugular venous distension, bilateral crackles, and an expiratory wheeze. His SpO2 is 88% on room air and it was noted that his urine output had been approximately 20 mL/hr since admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm.

Critical Thinking Check

Bloom's Taxonomy: Application

What nursing interventions should you perform right away for Mr. Jones?

VIEW ANSWER

Place into High Fowler’s position
Apply oxygen
Administer any PRN medications available for blood pressure (like hydralazine or metoprolol) if criteria are met
Notify the provider

Critical Thinking Check

Bloom's Taxonomy: Analysis

Describe what is happening to Mr. Jones physiologically.

VIEW ANSWER

Because his heart cannot pump blood efficiently to the body, the blood is backing up into the lungs. This causes pulmonary edema. His pulmonary edema is so severe that he is struggling to breathe and struggling to oxygenate appropriately.
His heart is trying to work extra hard to compensate for the low cardiac output, that’s why his blood pressure and heart rate are so elevated. This is perpetuated by the RAAS.
We also see that his kidneys are not being perfused as his urine output has decreased

Critical Thinking Check

Bloom's Taxonomy: Analysis

What medications should be given to decrease Mr. Jones’s preload? Improve his contractility? Decrease his afterload?

VIEW ANSWER

Preload – diuretics (furosemide, bumetanide, spironolactione), ACE inhibitors (captopril, enalapril), ARB’s (losartan, valsartan), ARNI’s (sacubitril/valsartan)
Contractility – Inotropes (dobutamine), cardiac glycosides (digoxin)
Afterload – Beta Blockers (metoprolol, carvedilol), vasodilators (hydralazine, nitrates)

Mr. Jones was transferred to the CCU for hemodynamic monitoring and aggressive therapy. His Central Venous Pressure (CVP) was found to be 19 mmHg, Cardiac Output was 4.5 L/min, Cardiac Index was 2.3 L/min/m2. He has been placed in high-fowler’s position, and his SpO2 is now 96% on 4L nasal cannula. Mr. Jones received Furosemide 80 mg IV and Digoxin 0.5 mg IV.

Critical Thinking Check

Bloom's Taxonomy: Comprehension

What is the expected outcome of administration of Furosemide? Digoxin?

VIEW ANSWER

Furosemide – should see increase in urine output and decrease in respiratory symptoms – may also see a decrease in any peripheral edema
Digoxin – decrease heart rate and increase the force of contraction – should see evidence of improved peripheral perfusion.