Congestive Heart Failure (CHF) Nursing Care Plan & Management

EXPLANATION

✔Correct answer:

Hypocapnia. In the early stages of pulmonary edema, the client often experiences tachypnea (rapid breathing) as a compensatory mechanism to improve oxygenation and reduce feelings of breathlessness. This rapid breathing results in excessive exhalation of carbon dioxide (CO₂), leading to hypocapnia (low PaCO₂). Despite this compensatory mechanism, the underlying gas exchange problem caused by fluid accumulation in the alveoli can still lead to hypoxemia (low PaO₂), but hypocapnia is a hallmark of the early stages before respiratory fatigue sets in.

Pulmonary edema involves the accumulation of fluid in the alveoli, impairing oxygen diffusion into the bloodstream. Early on, the body's response to hypoxemia is an increase in respiratory rate (tachypnea), which temporarily blows off CO₂, resulting in respiratory alkalosis (low PaCO₂, elevated pH). As the condition progresses, respiratory muscles may fatigue, and gas exchange worsens, leading to a rise in CO₂ (hypercapnia) and worsening hypoxemia.

Imagine a swimmer struggling to stay afloat in water (pulmonary edema). Initially, they breathe rapidly to get air (blow off CO₂), but as they tire and the water rises (worsening congestion), their breathing becomes less effective, leading to CO₂ buildup.

Identifying and addressing early signs of pulmonary edema is critical to preventing progression to severe respiratory failure.

• Monitor respiratory rate and effort closely, as tachypnea is one of the first clinical signs of pulmonary edema.
• Administer supplemental oxygen as prescribed to improve oxygen saturation and reduce respiratory effort.
• Position the client in high Fowler’s position to decrease venous return and improve lung expansion.
• Administer prescribed medications, such as diuretics (e.g., furosemide) to reduce fluid overload and vasodilators (e.g., nitroglycerin) to improve cardiac output.
• Repeat ABG analysis as needed to monitor for worsening gas exchange (e.g., development of hypercapnia).

✘Incorrect answer options:

Anoxia. Anoxia refers to a complete lack of oxygen in the tissues, which is a severe and late-stage complication of pulmonary edema. It is not an early ABG finding.

Hypercapnia. Hypercapnia (elevated PaCO₂) occurs in later stages of pulmonary edema, when respiratory muscles fatigue and the client is no longer able to compensate with rapid breathing. It suggests respiratory failure and would be associated with respiratory acidosis, not alkalosis.

Hyperoxygenation. Hyperoxygenation (excessive PaO₂) is not associated with pulmonary edema. Clients with pulmonary edema typically experience hypoxemia (low PaO₂) due to impaired gas exchange, rather than increased oxygen levels.

EXPLANATION

✔Correct answer:

Call for help. The first priority in managing a client with acute pulmonary edema is to call for help to ensure additional resources and immediate interventions can be initiated. Acute pulmonary edema is a medical emergency characterized by fluid accumulation in the lungs, causing severe respiratory distress, hypoxemia, and reduced oxygen delivery to tissues. Coughing up pink, frothy sputum is a hallmark sign of pulmonary edema, indicating significant fluid leakage into the alveoli. Prompt team involvement is critical because the condition can quickly progress to respiratory failure if not addressed immediately.

After calling for help, the nurse should begin additional life-saving interventions, such as positioning the client in high Fowler’s position to reduce venous return, providing supplemental oxygen, and preparing for diuretics or vasodilators as ordered.

In an emergency like a house fire (acute pulmonary edema), the first action is to alert the fire department (call for help) while taking immediate steps to stabilize the situation until they arrive.

Once additional help is on the way, Nurse Liam can focus on immediate actions to stabilize Ms. Harper’s condition.

• Position the client in high Fowler’s position to improve lung expansion and reduce pulmonary congestion.
• Administer supplemental oxygen to improve oxygenation and reduce hypoxemia.
• Monitor vital signs closely, including respiratory rate, oxygen saturation, and blood pressure, to detect worsening respiratory distress or hemodynamic instability.
• Prepare to administer prescribed medications:
  • Diuretics (e.g., furosemide) to reduce fluid overload.
  • Vasodilators (e.g., nitroglycerin) to reduce preload and afterload.
• Notify the physician after stabilizing the client and ensure rapid access to additional care, such as ICU transfer if necessary.

✘Incorrect answer options:

Notify the physician. While notifying the physician is important, it is not the first action in an emergency situation. Immediate stabilization measures, such as calling for help and addressing the client’s respiratory distress, must take precedence before contacting the physician.

Initiate an I.V. line. Establishing an I.V. line is a secondary priority in this situation. While I.V. access is important for administering medications like diuretics or vasodilators, the initial focus should be on ensuring airway patency, improving oxygenation, and reducing pulmonary congestion.

Suction the client. Suctioning may be necessary if the client has excessive secretions or airway obstruction, but it is not the first priority. The coughing of pink, frothy sputum is caused by fluid in the alveoli, not airway secretions, so positioning and oxygenation take precedence.

EXPLANATION

✔Correct answer:

Afterload. Afterload refers to the resistance the left ventricle (or right ventricle) must overcome to eject blood into the systemic (or pulmonary) circulation during systole. It is primarily determined by the diameter and elasticity of the blood vessels, particularly the systemic vascular resistance (SVR) in the case of the left ventricle. In conditions like hypertension or aortic stenosis, afterload increases because the ventricle must work harder to pump blood against the elevated resistance, leading to increased myocardial oxygen demand and potentially contributing to heart failure over time.

During systole, the heart contracts to pump blood out of the ventricles. If the resistance (afterload) is high, as in cases of systemic hypertension or arterial stiffness, the heart needs to generate more pressure to overcome that resistance. Over time, this increased workload can lead to ventricular hypertrophy and impaired cardiac function.

Think of the heart as a water pump. Afterload is like the pressure in the hose connected to the pump. If the hose is narrow or clogged (increased resistance), the pump has to work harder to push water through.

Understanding afterload is crucial when caring for clients with cardiac conditions, as interventions often focus on reducing afterload to improve cardiac output and reduce myocardial workload.

• Medications to reduce afterload:
  • Vasodilators (e.g., nitroglycerin, hydralazine) relax blood vessels, reducing systemic vascular resistance.
  • ACE inhibitors or ARBs lower blood pressure by inhibiting the renin-angiotensin-aldosterone system (RAAS), reducing afterload.
  • Beta-blockers reduce myocardial oxygen demand by decreasing heart rate and contractility.
• Monitor for signs of increased afterload, such as elevated blood pressure or symptoms of left-sided heart failure (e.g., dyspnea, crackles).
• Educate clients with conditions like hypertension or aortic stenosis about the importance of adhering to their treatment plan to prevent complications related to increased afterload.

✘Incorrect answer options:

Cardiac output. Cardiac output refers to the volume of blood the heart pumps per minute (calculated as heart rate × stroke volume). While afterload affects cardiac output by influencing the ease of ventricular ejection, it is a distinct concept.

Overload. "Overload" is not a specific cardiac physiology term. It may refer to fluid overload or volume overload in other contexts, but it does not describe the resistance the ventricle faces during systole.

Preload. Preload refers to the degree of stretch in the ventricles at the end of diastole, before contraction. It is determined by the volume of blood returning to the heart (venous return), not by the resistance during systole.

EXPLANATION

✔Correct answer:

Increased BP and fluid retention. When cardiac output decreases in heart failure, the body activates several compensatory mechanisms to maintain tissue perfusion and blood pressure. These mechanisms include increased blood pressure (BP) and fluid retention mediated by the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS):

1. SNS Activation: The sympathetic nervous system increases heart rate and vasoconstriction to maintain blood pressure and direct blood flow to vital organs. Vasoconstriction increases systemic vascular resistance (afterload), which can temporarily support blood pressure but further strains the failing heart.
2. RAAS Activation: Reduced renal perfusion due to low cardiac output triggers the release of renin, which activates the RAAS. Angiotensin II causes vasoconstriction (raising BP), and aldosterone promotes sodium and water retention to increase blood volume and preload. This fluid retention contributes to symptoms like edema and pulmonary congestion in heart failure.

While these compensatory mechanisms initially help maintain perfusion, they exacerbate the workload on the heart and worsen heart failure over time.

Imagine a water pump (the heart) that isn't working efficiently. To compensate, the system increases water pressure (blood pressure) and stores more water (fluid retention) to keep the pipes filled, but this eventually overloads the pump.

Nurses should focus on addressing both the symptoms of fluid overload and the underlying causes of decreased cardiac output to improve the client’s condition.

• Monitor for signs of fluid retention, such as peripheral edema, weight gain, and pulmonary congestion.
• Administer prescribed medications, such as:
  • Diuretics (e.g., furosemide) to reduce fluid retention and relieve symptoms of congestion.
  • ACE inhibitors or ARBs to block the RAAS, lowering blood pressure and reducing afterload.
  • Beta-blockers to reduce heart rate and myocardial oxygen demand, improving cardiac efficiency.
• Encourage adherence to a low-sodium diet and fluid restrictions to minimize fluid retention.
• Monitor for signs of worsening heart failure, such as increased shortness of breath, decreased urine output, or new arrhythmias.
• Provide client education on recognizing early symptoms of fluid overload and when to seek medical attention.

✘Incorrect answer options:

Decreased blood pressure (BP). Decreased BP may occur briefly as cardiac output declines, but the body’s compensatory mechanisms (SNS and RAAS activation) act to restore BP by increasing vasoconstriction and fluid retention. Persistent hypotension suggests decompensated heart failure or cardiogenic shock.

Alteration in level of consciousness (LOC). Altered LOC can occur if perfusion to the brain is severely impaired, but it is not the primary compensatory response. It indicates a worsening or decompensated state, rather than an early compensatory mechanism.

Decreased BP and diuresis. Diuresis (increased urine output) is not a compensatory response to decreased cardiac output. Instead, the body retains fluid through RAAS activation, leading to decreased urine output. Decreased BP and diuresis do not occur together in heart failure.

EXPLANATION

✔Correct answer:

Tomato juice. Tomato juice is high in sodium, especially when it is commercially prepared. Many canned or bottled tomato juices contain significant amounts of added salt to enhance flavor and preserve the product. A single serving (8 ounces) of regular tomato juice can contain approximately 600–700 mg of sodium, which is a substantial portion of the recommended daily limit for a client on a 2-gram sodium diet. Sodium intake must be restricted in heart failure clients to prevent fluid retention, reduce edema, and decrease the workload on the heart.

Sodium is a key contributor to fluid retention in the body. In clients with heart failure, excessive sodium intake leads to increased water retention due to the body's compensatory mechanisms. This can exacerbate symptoms like pulmonary congestion, edema, and hypertension, worsening the heart's ability to pump effectively. By limiting sodium intake, clients can manage their fluid balance more effectively, preventing the progression of heart failure.

Imagine the body as a sponge. When sodium is present, the sponge absorbs and retains water. By reducing sodium (like squeezing the sponge), the body retains less water, helping to ease the strain on the heart.

Education on sodium restriction is essential for effective heart failure management. Nurses should provide clients with clear guidance on avoiding high-sodium foods and reading food labels.

• Encourage clients to read food labels and choose low-sodium or no-added-salt options.
• Advise avoiding canned or processed foods, which often contain high levels of sodium.
• Suggest seasoning food with herbs and spices instead of salt to enhance flavor.
• Educate clients to monitor their daily sodium intake and keep a food diary to track compliance.
• Reinforce the importance of following the diet to help manage symptoms and prevent complications of heart failure.

✘Incorrect answer options:

Apples. Apples are a low-sodium fruit and are safe for clients on a 2-gram sodium diet. Fresh fruits are generally recommended because they are naturally low in sodium and provide essential vitamins, minerals, and fiber.

Whole wheat bread. While bread does contain some sodium (approximately 150–200 mg per slice), it is generally acceptable in moderation as part of a 2-gram sodium diet. Clients should choose whole-grain breads labeled "low-sodium" or "reduced-sodium" to further reduce intake.

Beef tenderloin. Fresh, unprocessed meats like beef tenderloin are naturally low in sodium and are appropriate for a sodium-restricted diet. However, processed or cured meats, such as sausages or deli meats, should be avoided due to their high sodium content.

EXPLANATION

✔Correct answer:

Digoxin. The symptoms of seeing green-yellow halos around lights and nausea are classic signs of digoxin toxicity, a condition caused by elevated levels of digoxin in the blood. Digoxin is a cardiac glycoside commonly used to treat heart failure and atrial fibrillation by increasing the contractility of the heart and controlling the heart rate. However, it has a narrow therapeutic index, meaning that even slight increases in serum digoxin levels can lead to toxicity. Other symptoms of digoxin toxicity include bradycardia, confusion, vomiting, diarrhea, and in severe cases, life-threatening arrhythmias.

Digoxin works by inhibiting the sodium-potassium ATPase pump in cardiac cells, which indirectly increases intracellular calcium levels, improving cardiac contractility. However, when serum digoxin levels rise too high, it disrupts the electrolyte balance (especially potassium and magnesium) and affects the electrical conduction in the heart and the retina, leading to visual disturbances like halos and neurological symptoms such as nausea.

Think of digoxin as a car engine additive meant to enhance performance. Adding the right amount improves engine function, but too much can cause the engine to overheat and misfire, just like digoxin toxicity disrupts the heart's and nervous system's proper function.

When digoxin toxicity is suspected, prompt intervention is crucial to prevent complications. Nurses should focus on monitoring cardiac function and electrolyte levels while collaborating with the healthcare provider to adjust treatment.

• Assess for early signs of digoxin toxicity, including visual disturbances (halos, blurred vision), gastrointestinal symptoms (nausea, vomiting), and changes in heart rate (bradycardia).
• Monitor serum digoxin levels. Therapeutic levels typically range from 0.5–2.0 ng/mL. Levels above this range indicate toxicity.
• Monitor potassium levels closely. Hypokalemia increases the risk of digoxin toxicity, as digoxin competes with potassium for binding sites on the sodium-potassium ATPase pump.
• Administer antidote if prescribed. Digoxin toxicity is treated with digoxin-specific antibody fragments (Digibind or DigiFab) in severe cases.
• Educate the patient on the importance of adhering to prescribed dosages and recognizing early symptoms of toxicity.

✘Incorrect answer options:

Furosemide (Lasix). Furosemide is a loop diuretic used to treat edema and hypertension by promoting the excretion of sodium, potassium, and water. While hypokalemia caused by furosemide can predispose a patient to digoxin toxicity, furosemide itself does not cause green-yellow halos or nausea.

Metoprolol (Lopressor). Metoprolol is a beta-blocker used to manage hypertension and certain arrhythmias. It may cause side effects like fatigue, bradycardia, or dizziness, but it is not associated with visual disturbances such as green-yellow halos or the other signs of digoxin toxicity.

Enalapril (Vasotec). Enalapril is an ACE inhibitor used to manage hypertension and heart failure. Its side effects may include a dry cough, hyperkalemia, or hypotension, but it does not cause visual disturbances like halos or other symptoms typical of digoxin toxicity.

EXPLANATION

✔Correct answer:

Hypertrophic. Hypertrophic cardiomyopathy (HCM) is the type of cardiomyopathy characterized by normal or even enhanced cardiac output, despite the presence of structural abnormalities in the heart. In HCM, the myocardial walls, particularly the interventricular septum, become abnormally thickened (hypertrophied). This hypertrophy can lead to impaired diastolic filling (diastolic dysfunction), but the heart's systolic function—and therefore cardiac output—often remains preserved. Some clients with HCM may even have a hyperdynamic left ventricle, leading to increased ejection fraction.

However, HCM can cause left ventricular outflow tract (LVOT) obstruction in some clients, as the thickened septum obstructs the flow of blood from the left ventricle to the aorta. This obstruction, combined with diastolic dysfunction, can lead to symptoms such as dyspnea, angina, syncope, and exercise intolerance, despite preserved cardiac output.

In HCM, the thickened myocardium reduces the compliance of the left ventricle, impairing its ability to fill with blood during diastole. However, the systolic function (ejection of blood) is usually unaffected or even hyperdynamic. In cases where LVOT obstruction occurs, it can lead to increased pressures in the left atrium and pulmonary circulation, but cardiac output may still be preserved unless the obstruction becomes severe.

Think of a water pump (the heart) that has a narrower pipe (the left ventricular outflow tract) due to thick walls (hypertrophy). The pump still pushes out water efficiently, but the narrowed path can cause strain, leading to symptoms like shortness of breath or chest pain.

Management of hypertrophic cardiomyopathy focuses on alleviating symptoms, improving diastolic filling, and preventing complications such as arrhythmias or sudden cardiac death.

• Administer prescribed medications, such as:
  • Beta-blockers to reduce heart rate and improve diastolic filling.
  • Calcium channel blockers (e.g., verapamil) to relax the myocardium and improve compliance.
  • Antiarrhythmic drugs for clients with atrial fibrillation or ventricular arrhythmias.
• Monitor for symptoms of outflow obstruction, such as syncope, angina, or dyspnea, particularly during exertion.
• Educate clients to avoid strenuous exercise or dehydration, as these can worsen symptoms and increase the risk of arrhythmias or sudden cardiac death.
• Prepare clients for potential advanced treatments, such as septal myectomy (surgical removal of part of the thickened septum) or implantable cardioverter defibrillators (ICDs) for high-risk clients.
• Encourage genetic counseling and screening for family members, as HCM is often inherited in an autosomal dominant pattern.

✘Incorrect answer options:

Dilated. Dilated cardiomyopathy is characterized by a weakened, enlarged left ventricle and reduced cardiac output due to impaired systolic function. This is the most common type of cardiomyopathy that leads to heart failure with reduced ejection fraction (HFrEF).

Obliterative. Obliterative cardiomyopathy is not a widely recognized or commonly used term in the classification of cardiomyopathies. It is sometimes used synonymously with restrictive cardiomyopathy but does not specifically describe conditions with preserved cardiac output.

Restrictive. Restrictive cardiomyopathy is associated with stiff ventricular walls that impair diastolic filling, leading to reduced cardiac output over time. This type is commonly seen in conditions such as amyloidosis or sarcoidosis and is associated with severe diastolic dysfunction, not preserved cardiac output.

EXPLANATION

✔Correct answer:

In high Fowler’s position. The most beneficial position for a client with acute pulmonary edema is the high Fowler’s position, where the client is sitting upright at a 90-degree angle. This position helps relieve severe shortness of breath by:

1. Reducing preload: Sitting upright decreases venous return to the heart by pooling blood in the lower extremities, which helps reduce fluid congestion in the lungs.
2. Improving lung expansion: Elevating the torso allows the diaphragm to move more freely, improving lung expansion and gas exchange.
3. Enhancing oxygenation: By reducing the pressure of fluid in the lungs and promoting better ventilation, the high Fowler’s position facilitates oxygen delivery to the blood.

Acute pulmonary edema is a life-threatening condition caused by fluid accumulation in the alveoli, often due to left-sided heart failure. The increased pulmonary venous pressure leads to fluid leaking into the lungs, impairing gas exchange and causing dyspnea, orthopnea, and hypoxia.

Imagine a sponge (the lungs) soaked with water (fluid). Holding the sponge upright lets some water drain downward, relieving pressure and allowing air to circulate more freely through the sponge.

Positioning the client in high Fowler’s is one of the first and most effective interventions to relieve symptoms of pulmonary edema. It should be followed by other measures to stabilize the client.

• Administer supplemental oxygen as prescribed to improve oxygen saturation and prevent hypoxia.
• Monitor vital signs (e.g., oxygen saturation, respiratory rate, and blood pressure) and observe for signs of worsening respiratory distress.
• Administer prescribed medications, such as:
  • Diuretics (e.g., furosemide) to reduce fluid volume and alleviate pulmonary congestion.
  • Vasodilators (e.g., nitroglycerin) to reduce preload and afterload, improving cardiac output.
  • Morphine (in selected cases) to reduce anxiety, preload, and oxygen demand.
• Reassure the client and provide emotional support, as severe shortness of breath can cause significant anxiety.

✘Incorrect answer options:

Lying flat in bed. Lying flat worsens pulmonary edema by increasing venous return to the heart, further raising pulmonary congestion and exacerbating shortness of breath. It also reduces lung expansion, making breathing more difficult.

Left side-lying. The left side-lying position does not provide significant relief for pulmonary edema and may worsen symptoms by increasing blood flow to the lungs due to gravity, further contributing to fluid congestion.

In semi-Fowler’s position. The semi-Fowler’s position (elevating the head of the bed to about 30–45 degrees) provides some relief but is less effective than the high Fowler’s position in reducing venous return and improving lung expansion in acute pulmonary edema.

EXPLANATION

✔Correct answer:

Inotropic agents. Inotropic agents are medications that enhance cardiac performance by increasing the strength of ventricular contractions. They are commonly used in the management of heart failure, especially when the heart's pumping ability is impaired. These agents work by increasing the force of myocardial contractility, which improves cardiac output and tissue perfusion. Examples of positive inotropic agents include digoxin, dobutamine, and milrinone.

In heart failure, the heart's ability to pump blood effectively is diminished, resulting in inadequate cardiac output. Inotropic agents improve this condition by increasing intracellular calcium levels within the myocardial cells, thereby enhancing the force of contraction (a mechanism known as positive inotropy). This can help alleviate symptoms like fatigue, shortness of breath, and fluid retention by improving systemic perfusion and reducing venous congestion.

Think of the heart as a water pump. If the pump's motor (ventricular contractions) is weak, it can't push water (blood) effectively through the pipes (blood vessels). Inotropic agents act like a stronger motor, allowing the pump to push water more efficiently and prevent flooding (fluid backup).

When administering inotropic agents, nurses should monitor the patient's response carefully, as these medications can have significant effects on heart rate, rhythm, and blood pressure.

• Assess for therapeutic effects, such as improved cardiac output, reduced edema, and increased urine output.
• Monitor for adverse effects, including arrhythmias (e.g., tachycardia or bradycardia), as inotropic agents can affect the heart's electrical activity.
• Check electrolyte levels, particularly potassium and magnesium, as imbalances can increase the risk of cardiac arrhythmias.
• Observe for signs of digoxin toxicity (if applicable), such as nausea, visual disturbances, and bradycardia, and ensure serum digoxin levels are within the therapeutic range (0.5–2.0 ng/mL).
• Educate the client about the purpose of the medication and the importance of reporting any new or worsening symptoms promptly.

✘Incorrect answer options:

Beta-adrenergic blockers. Beta-blockers, such as metoprolol and carvedilol, are used in heart failure to reduce myocardial oxygen demand and improve ventricular remodeling. However, they do not enhance the force of contraction and instead work by slowing the heart rate and reducing afterload.

Calcium channel blockers. Calcium channel blockers, such as amlodipine and diltiazem, are primarily used for hypertension and certain arrhythmias. While they affect calcium movement, they generally reduce myocardial contractility (negative inotropic effect) and are not used to improve pumping strength in heart failure.

Diuretics. Diuretics, such as furosemide and hydrochlorothiazide, are used to manage fluid overload in heart failure by promoting the excretion of sodium and water. While they relieve symptoms like edema and dyspnea, they do not directly enhance cardiac contractility.

EXPLANATION

✔Correct answer:

Beta-adrenergic blockers. Beta-adrenergic blockers (beta-blockers) are a key class of drugs widely used in the management of cardiomyopathy. These medications work by blocking beta-adrenergic receptors, which reduces the effects of the sympathetic nervous system on the heart. This results in a decrease in heart rate, reduction in myocardial oxygen demand, and improved diastolic filling time. By lowering the workload on the heart and decreasing myocardial oxygen consumption, beta-blockers can help improve symptoms and prevent disease progression, particularly in clients with dilated cardiomyopathy (DCM) or hypertrophic cardiomyopathy (HCM).

In cardiomyopathy, the heart's ability to pump blood effectively is impaired, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Beta-blockers, such as metoprolol, carvedilol, and bisoprolol, play a critical role in improving cardiac function by:

• Reducing heart rate, which allows the ventricles more time to fill during diastole.
• Decreasing afterload, which reduces the force needed for the heart to eject blood.
• Preventing arrhythmias, which are common complications in cardiomyopathy.
• Protecting the myocardium from further damage caused by excessive sympathetic stimulation.

Think of beta-blockers as reducing the "speed" of the heart's engine. Slowing the engine allows it to work more efficiently, with less wear and tear, while still maintaining adequate performance.

When administering beta-blockers to clients with cardiomyopathy, nurses should monitor for potential side effects and ensure the medication is achieving its therapeutic goals.

• Monitor heart rate and blood pressure before administering beta-blockers. Hold the medication and notify the healthcare provider if the heart rate is <60 bpm or if systolic blood pressure is <90 mmHg, unless otherwise directed.
• Educate the client about common side effects, including fatigue, dizziness, and bradycardia, and encourage adherence to the prescribed regimen.
• Assess for signs of worsening heart failure, such as increased shortness of breath, weight gain, or peripheral edema.
• Advise the client to avoid abrupt discontinuation of beta-blockers, as this can lead to rebound tachycardia or hypertension.
• Reinforce the importance of combining beta-blockers with other heart failure treatments, such as ACE inhibitors, diuretics, and lifestyle changes, for optimal symptom management.

✘Incorrect answer options:

Antihypertensives. While antihypertensives, such as ACE inhibitors and angiotensin receptor blockers (ARBs), are often used alongside beta-blockers in the treatment of cardiomyopathy, they are not the primary class of drugs for reducing heart workload. Their primary role is to reduce afterload and promote ventricular remodeling, rather than directly modulating heart rate or sympathetic activity.

Calcium channel blockers. Calcium channel blockers, such as verapamil or diltiazem, may be used in specific cases of hypertrophic cardiomyopathy to reduce ventricular stiffness and improve diastolic filling. However, they are not as widely used as beta-blockers in the overall management of cardiomyopathy. In dilated cardiomyopathy, calcium channel blockers are generally avoided due to their negative inotropic effects, which can worsen systolic dysfunction.

Nitrates. Nitrates, such as nitroglycerin, are vasodilators primarily used to relieve angina by reducing myocardial oxygen demand and preload. They are not first-line medications for managing cardiomyopathy, as they do not specifically target the underlying pathophysiology of the condition.

EXPLANATION

✔Correct answer:

Normal sinus rhythm. The findings described—an atrial and ventricular rate of 80 beats per minute, a PR interval of 0.14 seconds, and a QRS complex of 0.08 seconds—are all within normal limits for a healthy cardiac rhythm. These values indicate that the client is in normal sinus rhythm (NSR).

Key Characteristics of Normal Sinus Rhythm:

1. Rate: 60–100 beats per minute.
2. Rhythm: Regular atrial and ventricular rhythm.
3. P waves: Consistent in shape, upright, and preceding each QRS complex.
4. PR interval: 0.12–0.20 seconds (indicates normal conduction from the sinoatrial (SA) node through the atrioventricular (AV) node).
5. QRS complex: ≤0.10 seconds (indicates normal ventricular depolarization).

In this case, the rate (80 bpm), PR interval (0.14 seconds), and QRS complex (0.08 seconds) are all within normal parameters, confirming that the rhythm is normal sinus rhythm.

Think of the heart as a metronome that sets the pace for the body. In normal sinus rhythm, the "ticks" (heartbeats) are steady, rhythmic, and occur at an expected speed—just like a well-functioning metronome.

When identifying normal sinus rhythm on an ECG strip, no immediate intervention is necessary since this is a normal finding. However, ongoing monitoring and assessment of the client's overall condition are essential.

• Continue routine ECG monitoring to detect any changes in rhythm or rate.
• Evaluate the client's vital signs and symptoms to ensure they remain hemodynamically stable (e.g., adequate blood pressure, oxygen saturation).
• Document the findings as normal sinus rhythm in the client’s medical record.
• Educate the client about factors that promote healthy cardiac function, such as proper diet, exercise, and stress management.
• If the client has a history of arrhythmias, ensure they understand how to report symptoms like palpitations, dizziness, or chest pain promptly.

✘Incorrect answer options:

Sinus bradycardia: Sinus bradycardia is characterized by a heart rate of less than 60 beats per minute. Since this client has a rate of 80 beats per minute, this option is incorrect.

Sinus tachycardia: Sinus tachycardia occurs when the heart rate exceeds 100 beats per minute while maintaining a normal rhythm. The client’s heart rate of 80 beats per minute is well within the normal range, so this option is not accurate.

Sinus dysrhythmia: Sinus dysrhythmia (or sinus arrhythmia) is an irregular rhythm often associated with changes in intrathoracic pressure during breathing, where the heart rate speeds up during inspiration and slows down during expiration. In this case, the rhythm is described as regular, making sinus dysrhythmia an incorrect interpretation.

EXPLANATION

✔Correct answer:

Premedicate the client with an analgesic. After cardiac surgery, clients often experience pain at the surgical site, especially when engaging in activities like ambulation that involve movement of the chest wall. Premedicating the client with an analgesic before ambulation is an essential nursing intervention to reduce pain and help the client tolerate the activity more comfortably and safely. Pain control promotes mobility, which is critical for preventing complications such as deep vein thrombosis (DVT), pulmonary complications (e.g., atelectasis), and delayed recovery.

Administering pain medication 30 minutes to 1 hour before activity allows the analgesic to take effect, minimizing discomfort during movement. This ensures the client is more willing and physically capable of participating in ambulation, which is a key component of post-operative care to enhance recovery.

Imagine trying to walk with a pebble in your shoe—it’s painful and slows you down. Removing the pebble (or in this case, pre-treating pain with medication) makes the activity much more manageable and encourages progress.

When preparing a post-cardiac surgery client for ambulation, the nurse should focus on safety, comfort, and optimal recovery.

• Administer prescribed analgesics prior to ambulation to reduce pain and promote participation in mobility exercises.
• Assist the client to a sitting position and allow them to dangle their legs at the bedside to prevent dizziness or orthostatic hypotension.
• Monitor vital signs (heart rate, blood pressure, and oxygen saturation) before, during, and after ambulation to assess for tolerance and any complications.
• Provide support, such as assistance with walking or the use of a gait belt, to ensure safety and prevent falls.
• Encourage the client to gradually increase their activity level over time as tolerated.

✘Incorrect answer options:

Encourage the client to cough and take a deep breath: While coughing and deep breathing are essential post-operative interventions to prevent pulmonary complications (e.g., atelectasis), this option does not directly address the client’s pain or comfort during ambulation. These exercises are more relevant for respiratory care, not activity tolerance.

Provide the client with a walker: Most cardiac surgery clients do not require a walker unless they have pre-existing mobility issues or specific conditions affecting balance or strength. Providing a walker unnecessarily may discourage normal mobility and reduce confidence in walking independently.

Remove telemetry equipment because it weighs down the hospital gown: Telemetry equipment is vital for monitoring cardiac function post-surgery and must remain in place unless cleared by the healthcare provider. The minimal weight of the equipment does not significantly affect the client’s ability to ambulate and is critical for identifying any arrhythmias or complications during activity.

EXPLANATION

✔Correct answer:

Ineffective tissue perfusion; cardiopulmonary. The priority nursing diagnosis for a client with an acute inferior-wall myocardial infarction (MI) is Ineffective tissue perfusion; cardiopulmonary. Myocardial infarction occurs due to impaired blood flow in the coronary arteries, resulting in reduced oxygen delivery to the heart muscle (ischemia). This leads to ineffective tissue perfusion, which can cause life-threatening complications, including arrhythmias, cardiogenic shock, and myocardial damage. Addressing cardiopulmonary tissue perfusion is critical to restoring blood flow to the myocardium, minimizing tissue damage, and preventing further complications.

Inferior-wall MIs often involve the right coronary artery (RCA), which supplies blood to the right ventricle and the conduction system (e.g., SA node, AV node). These MIs are commonly associated with bradycardia and hypotension, requiring close monitoring and immediate interventions such as oxygen, nitroglycerin (cautiously, if hypotension is present), and potentially thrombolytic therapy or percutaneous coronary intervention (PCI) to restore perfusion.

Imagine a hose (coronary artery) delivering water (oxygenated blood) to a garden (heart muscle). A blockage in the hose stops water flow, causing the plants to wilt (ischemia). Restoring water flow quickly is critical to saving the garden, just as restoring blood flow is essential to preserve heart tissue.

Addressing ineffective tissue perfusion involves interventions to restore blood flow, reduce myocardial oxygen demand, and prevent complications.

• Administer oxygen as prescribed to improve oxygen delivery to the myocardium.
• Administer prescribed medications, such as:
  • Aspirin to prevent further clot formation.
  • Nitroglycerin (if blood pressure allows) to improve coronary artery dilation and reduce preload.
  • Beta-blockers (e.g., metoprolol) to decrease heart rate and myocardial oxygen demand, unless contraindicated (e.g., hypotension, bradycardia).
• Prepare the client for reperfusion therapy, such as thrombolysis or PCI, to restore blood flow to the blocked coronary artery.
• Monitor for complications, including arrhythmias, hypotension, or heart failure, which are common in inferior-wall MIs.
• Reassess tissue perfusion by monitoring vital signs, cardiac rhythm, oxygen saturation, and chest pain relief.

✘Incorrect answer options:

Anxiety. Anxiety is a common response to acute MIs due to fear, pain, or uncertainty about the condition. While important, anxiety is not life-threatening and does not take priority over restoring cardiopulmonary tissue perfusion.

Acute pain. Chest pain is a hallmark symptom of MI, caused by myocardial ischemia. However, the pain is a result of impaired tissue perfusion. The priority is to restore oxygenation and blood flow, which will simultaneously relieve pain.

Ineffective therapeutic regimen management. Stopping prescribed medications, such as metoprolol, may have contributed to the MI. However, this diagnosis focuses on long-term adherence and does not address the immediate, life-threatening issue of impaired perfusion.

EXPLANATION

✔Correct answer:

Peptic ulcer disease. While peptic ulcer disease (PUD) is a significant gastrointestinal condition that can cause discomfort and complications such as bleeding, it is least likely to directly contribute to the exacerbation of heart failure. PUD does not significantly affect cardiac workload, fluid balance, or myocardial oxygen demand, which are critical factors in the progression of heart failure. However, if PUD causes severe anemia due to bleeding, this could indirectly worsen heart failure, but this is not a primary or frequent link.

Heart failure exacerbations are typically driven by conditions that increase myocardial workload, reduce cardiac output, or affect oxygen delivery, such as infections, arrhythmias, or volume overload.

Think of heart failure as a car engine under strain. While issues like a weak battery (infection or arrhythmia) or low-quality fuel (anemia) can worsen strain on the engine, an unrelated issue like a crack in the car’s paint (peptic ulcer disease) doesn’t directly affect the engine’s performance.

Although PUD is not a direct contributor to heart failure exacerbations, nurses should still address gastrointestinal symptoms and educate clients on managing this condition alongside their cardiac health.

✘Incorrect answer options:

Recent upper respiratory infection (URI). Respiratory infections can significantly worsen heart failure by increasing the body’s oxygen demand, causing systemic inflammation, and worsening pulmonary congestion. Clients with heart failure often have compromised respiratory systems, so URIs can exacerbate symptoms such as dyspnea and fluid retention.

Nutritional anemia. Anemia reduces oxygen-carrying capacity, forcing the heart to work harder to meet the body's oxygen demands. This increases myocardial oxygen consumption and workload, which can worsen symptoms of heart failure, especially in clients with already impaired cardiac output.

Atrial fibrillation (A-Fib). A-Fib is a common arrhythmia associated with heart failure. It reduces cardiac output by impairing atrial contraction and can lead to rapid ventricular response (RVR), increasing myocardial workload. A-Fib is a significant contributor to heart failure exacerbations and must be closely managed.

EXPLANATION

✔Correct answer:

Heart failure. The symptoms of shortness of breath (dyspnea), persistent cough, fatigue, and swelling in the lower extremities are hallmark signs of heart failure. Heart failure occurs when the heart is unable to pump blood effectively to meet the body's needs, leading to a buildup of fluid in various parts of the body. These symptoms result from a combination of left-sided and right-sided heart failure:

• Left-sided heart failure: Blood backs up into the lungs (pulmonary congestion), causing symptoms such as shortness of breath, orthopnea (difficulty breathing when lying flat), a persistent cough (often with frothy, pink-tinged sputum), and fatigue due to reduced oxygenation.
• Right-sided heart failure: Blood backs up into the systemic circulation, causing symptoms like peripheral edema (swelling in the lower extremities), jugular vein distention (JVD), ascites, and weight gain due to fluid retention.

In heart failure, the heart's reduced ability to pump blood effectively results in decreased cardiac output and fluid retention. This triggers compensatory mechanisms, including activation of the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system. While these mechanisms temporarily support circulation, they worsen fluid overload and lead to the systemic and pulmonary symptoms seen in heart failure.

Think of the heart as a water pump. If the pump is weak (heart failure), water (blood) doesn’t move efficiently. This leads to flooding in the basement (lungs, causing shortness of breath and cough) and pooling outside the house (legs, causing swelling).

The management of heart failure focuses on relieving symptoms, optimizing cardiac output, and preventing disease progression.

• Assess for signs of pulmonary and systemic congestion, including lung crackles, dyspnea, peripheral edema, and JVD.
• Administer prescribed medications, such as:
  • Diuretics to reduce fluid overload and alleviate symptoms of pulmonary and peripheral congestion.
  • ACE inhibitors or angiotensin receptor blockers (ARBs) to lower afterload and improve cardiac output.
  • Beta-blockers to reduce myocardial workload and control heart rate.
  • Aldosterone antagonists to manage fluid retention.
• Monitor daily weights and fluid balance (intake and output) to assess for fluid retention or dehydration.
• Educate the client on dietary modifications, such as reducing sodium intake and adhering to fluid restrictions, to manage symptoms of heart failure.
• Encourage the client to recognize early signs of worsening heart failure, such as rapid weight gain, increasing dyspnea, or worsening edema, and to seek prompt medical attention.

✘Incorrect answer options:

Pericarditis. Pericarditis, or inflammation of the pericardial sac, typically causes sharp chest pain that worsens with inspiration or lying flat. It may also cause a pericardial friction rub upon auscultation, but it does not commonly result in fluid retention, pulmonary congestion, or systemic edema.

Hypertension. While hypertension is a significant risk factor for heart failure, it does not directly cause symptoms such as persistent cough, shortness of breath, or leg swelling. However, uncontrolled hypertension over time can lead to heart failure.

Myocardial infarction (MI). An MI occurs when blood flow to a portion of the heart is blocked, causing myocardial ischemia. Symptoms of MI typically include chest pain, shortness of breath, nausea, diaphoresis, and ECG changes, but it does not commonly cause fluid retention or systemic congestion unless it progresses to heart failure.

EXPLANATION

✔Correct answer:

Cardiomyopathy. Cardiomyopathy refers to a group of diseases that affect the structure and function of the heart muscle and can often develop independently of other cardiovascular conditions. While some types of cardiomyopathy, such as ischemic cardiomyopathy, are linked to coronary artery disease or heart attacks, primary cardiomyopathy occurs as a standalone condition without a direct connection to other cardiovascular diseases. It may result from genetic mutations, infections, toxins (e.g., alcohol, chemotherapy), or unknown causes. Cardiomyopathy can be classified into different types, including dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy, each with distinct pathophysiological mechanisms.

Cardiomyopathy involves changes in the heart muscle, which can impair the heart’s ability to pump blood effectively. Depending on the type, this may involve dilation of the ventricles, thickening of the myocardium, or stiffening of the heart walls. For example:

• Dilated cardiomyopathy results in weakened, enlarged ventricles.
• Hypertrophic cardiomyopathy involves abnormal thickening of the myocardium, often with genetic origins.
• Restrictive cardiomyopathy is characterized by rigid ventricular walls that impair filling.

Unlike secondary forms of cardiomyopathy, primary cardiomyopathy is not directly caused by other cardiovascular conditions such as hypertension or coronary artery disease.

Think of the heart as a car engine. In cardiomyopathy, the engine malfunctions due to internal mechanical issues (e.g., manufacturing defects or wear), not because of external factors like a clogged fuel line (coronary artery disease) or lack of fuel (ischemia).

Nurses should focus on managing symptoms, improving quality of life, and preventing complications in clients with cardiomyopathy.

• Monitor for signs of heart failure, such as dyspnea, fatigue, and fluid retention, as these can occur in advanced cardiomyopathy.
• Administer prescribed medications, such as beta-blockers, ACE inhibitors, or diuretics, to improve cardiac output and reduce symptoms.
• Educate the client about lifestyle modifications, including limiting alcohol intake, avoiding strenuous activity (for hypertrophic cardiomyopathy), and adhering to a low-sodium diet.
• Assess for arrhythmias, as clients with cardiomyopathy are at increased risk of ventricular tachycardia or fibrillation.
• Discuss the potential need for advanced therapies, such as implantable cardioverter defibrillators (ICDs) or heart transplants in severe cases.

✘Incorrect answer options:

Coronary artery disease. Coronary artery disease (CAD) is a condition caused by atherosclerosis in the coronary arteries and is directly linked to other cardiovascular diseases, including myocardial infarction and ischemic cardiomyopathy. CAD does not occur independently of other cardiovascular issues.

Myocardial infarction. Myocardial infarction (heart attack) results from an obstruction in the coronary arteries, which is closely associated with conditions such as coronary artery disease, hypertension, and hyperlipidemia. It is not an independent disease.

Pericardial effusion. Pericardial effusion, the accumulation of fluid in the pericardial sac, is usually secondary to other conditions, such as pericarditis, cancer, or cardiac surgery. It does not typically occur independently and is often associated with systemic or cardiovascular diseases.

EXPLANATION

✔Correct answer:

Right-sided heart failure. Sacral edema is most commonly associated with right-sided heart failure in bedridden clients. Right-sided heart failure occurs when the right ventricle is unable to pump blood effectively into the pulmonary circulation, leading to a backup of blood into the systemic venous system. This venous congestion causes fluid to accumulate in dependent areas of the body due to gravity. In ambulatory clients, this often manifests as peripheral edema in the legs and feet. However, in bedridden clients, the dependent area is the sacral region, leading to sacral edema. Other signs of right-sided heart failure include jugular vein distention (JVD), hepatomegaly, ascites, and weight gain due to fluid retention.

In right-sided heart failure, the failure of the right ventricle to pump blood forward into the pulmonary circulation results in increased venous pressure. This causes fluid to leak from the capillaries into the interstitial spaces, particularly in areas where gravity favors fluid pooling. For bedridden patients, this pooling occurs in the sacral area, resulting in visible and palpable edema.

Think of the bloodstream as a highway and the right ventricle as a toll booth directing traffic into the lungs. If the toll booth is slow (right-sided heart failure), cars (blood) back up, causing congestion and flooding (fluid accumulation) in nearby areas. For someone lying down, this congestion settles in the sacral region due to gravity.

Managing sacral edema involves addressing the underlying cause (e.g., right-sided heart failure) while preventing complications like skin breakdown and further fluid retention.

• Regularly assess dependent areas, including the sacral region, for signs of edema or skin breakdown.
• Reposition the patient frequently (at least every 2 hours) to reduce pressure on dependent areas and improve circulation.
• Administer prescribed diuretics, such as furosemide, to reduce fluid overload and alleviate venous congestion.
• Encourage a low-sodium diet to minimize fluid retention and improve heart failure symptoms.
• Use appropriate skin protection measures, such as barrier creams and pressure-relieving mattresses, to prevent pressure ulcers.
• Monitor weight daily as a measure of fluid retention and assess for other signs of worsening heart failure, such as JVD and increased dyspnea.

✘Incorrect answer options:

Diabetes. While diabetes can lead to complications like peripheral neuropathy and poor circulation, it is not directly associated with sacral edema. Diabetes is more likely to contribute to chronic wounds or infections but does not cause fluid accumulation in dependent areas.

Pulmonary embolism. A pulmonary embolism is a sudden blockage of a pulmonary artery, typically caused by a blood clot. Symptoms include acute shortness of breath, chest pain, and tachycardia, but it does not cause systemic venous congestion or sacral edema.

Renal failure. Renal failure can cause generalized edema (anasarca) due to fluid retention and hypoalbuminemia, but the edema is not limited to dependent areas like the sacral region. Instead, it typically involves the face, hands, and lower extremities in ambulatory clients.

EXPLANATION

✔Correct answer:

Activate the resuscitation team. According to the American Heart Association (AHA) Basic Life Support (BLS) guidelines, the first step after confirming that a client is unresponsive is to activate the emergency response system (e.g., call the resuscitation team or code blue). This ensures that help is on the way while the nurse begins initiating life-saving measures like chest compressions if needed. Early activation of the resuscitation team is critical because cardiac arrest requires prompt intervention to improve the chances of survival.

After activating the resuscitation team, the nurse should quickly assess the client’s breathing and pulse (simultaneously for no more than 10 seconds). If there is no breathing or pulse, immediate chest compressions should be started at a rate of 100–120 compressions per minute.

Imagine a fire in a house. The first action is to call the fire department (activate the resuscitation team) before attempting to control the fire yourself, ensuring the situation gets professional attention as soon as possible.

Rapid recognition and response are essential to improving survival rates in cases of cardiac arrest.

• Confirm unresponsiveness by tapping the client and shouting, "Are you okay?" to ensure the client is truly unresponsive.
• Activate the emergency response system (e.g., call a code blue or resuscitation team) immediately upon confirming unresponsiveness.
• Quickly assess for breathing and pulse simultaneously, within no more than 10 seconds.
• If there is no pulse, begin high-quality chest compressions immediately (compression depth of 2 inches for adults, allowing full recoil).
• Prepare for the use of an automated external defibrillator (AED) or manual defibrillator if the client is in a shockable rhythm (e.g., ventricular fibrillation or pulseless ventricular tachycardia).

✘Incorrect answer options:

Open the client’s airway. Opening the airway is part of the A (Airway) step of the CAB sequence (Circulation, Airway, Breathing). However, it is not the first action. Activating the resuscitation team takes precedence to ensure timely assistance, as airway management will depend on whether the client is breathing and has a pulse.

Check for breathing. While assessing for breathing is a critical step, it is not the first priority after confirming unresponsiveness. Activating the resuscitation team ensures that additional help arrives quickly to manage the situation effectively.

Check for signs of circulation. Checking for circulation (e.g., pulse) is important, but it is not the first step after confirming unresponsiveness. Ensuring that help is on the way by activating the resuscitation team takes precedence before further assessments.

EXPLANATION

✔Correct answer:

Vasodilator. Captopril is an angiotensin-converting enzyme (ACE) inhibitor that acts as a vasodilator. Its primary action in treating heart failure is to block the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. By reducing the levels of angiotensin II, captopril causes vasodilation, which decreases systemic vascular resistance and blood pressure. This action reduces the workload on the heart by lowering afterload (the resistance the heart must pump against) and preload (the volume of blood returning to the heart), thereby improving cardiac output and alleviating symptoms of heart failure.

Heart failure is characterized by the heart's inability to pump sufficient blood to meet the body's needs. The renin-angiotensin-aldosterone system (RAAS) is often activated in heart failure, leading to vasoconstriction, fluid retention, and increased workload on the heart. Captopril interrupts this compensatory mechanism, promoting vasodilation and diuresis, which helps to control symptoms like fluid overload and hypertension.

Imagine your heart as a pump trying to push water through a hose. If the hose is tightly squeezed (vasoconstriction), the pump has to work harder to move the water. Captopril relaxes the hose (vasodilation), allowing the water to flow more easily and reducing the strain on the pump.

Nurses administering captopril should focus on monitoring for side effects, educating the client about the medication, and evaluating the therapeutic response.

• Monitor the client’s blood pressure and pulse before and after administration, as captopril can cause hypotension.
• Assess for signs of hyperkalemia, as ACE inhibitors can increase potassium levels.
• Monitor for signs of angioedema (e.g., swelling of the face, lips, or throat), which is a rare but serious side effect.
• Educate the client to report any persistent dry cough, which is a common side effect of ACE inhibitors.
• Encourage regular follow-ups to monitor kidney function (BUN, creatinine) and electrolytes.

✘Incorrect answer options:

Vasopressor. Captopril is not a vasopressor. Vasopressors, such as norepinephrine or dopamine, cause vasoconstriction to increase blood pressure and are used in cases of hypotension or shock, not heart failure management. Captopril works in the opposite way by causing vasodilation.

Volume expander. Captopril does not expand blood volume. Volume expanders, such as colloids or crystalloids, are used to restore intravascular volume in cases of hypovolemia, which is not the primary issue in heart failure.

Potassium-sparing diuretic. Captopril is not a diuretic, but it can indirectly promote diuresis by reducing aldosterone levels. Potassium-sparing diuretics, such as spironolactone, are often used alongside ACE inhibitors in heart failure management but have a different mechanism of action.

EXPLANATION

✔Correct answer:

Hypertrophic. Hypertrophic cardiomyopathy (HCM) is characterized by the thickening of the myocardial walls, most commonly the interventricular septum, leading to impaired ventricular filling and potential outflow obstruction. HCM is typically a genetic condition caused by mutations in sarcomeric proteins that regulate cardiac muscle contraction. The hypertrophy is often asymmetric, predominantly affecting the septum, and can lead to obstruction of blood flow from the left ventricle to the aorta (hypertrophic obstructive cardiomyopathy, or HOCM). Other effects include reduced ventricular compliance, diastolic dysfunction, and an increased risk of arrhythmias and sudden cardiac death.

In HCM, the thickened septum and ventricular walls reduce the size of the left ventricular chamber, limiting the heart's ability to fill during diastole (diastolic dysfunction). The abnormal thickening also disrupts the normal alignment of myocardial cells (myocyte disarray), contributing to electrical instability and arrhythmias. If the hypertrophied septum obstructs the left ventricular outflow tract, symptoms such as dyspnea, chest pain, and syncope can occur.

Imagine a hallway (the left ventricular outflow tract) with a thick wall (hypertrophied septum) that narrows the pathway, making it harder for people (blood) to move through. Additionally, the thick wall takes up space, reducing the room available in the hallway for people to gather (ventricular filling).

The management of HCM focuses on symptom control, improving ventricular filling, and preventing complications like arrhythmias or sudden cardiac death.

• Monitor for symptoms of HCM, such as dyspnea, chest pain, syncope, or palpitations, which may worsen with exertion.
• Administer prescribed medications, such as:
  • Beta-blockers to reduce heart rate and myocardial oxygen demand.
  • Calcium channel blockers (e.g., verapamil) to improve diastolic filling and relaxation.
  • Antiarrhythmic drugs to manage atrial fibrillation or ventricular arrhythmias.
• Educate the client to avoid strenuous exercise or activities that increase heart rate, as these can exacerbate symptoms.
• Monitor for and manage complications, such as arrhythmias or heart failure, and prepare the client for advanced interventions like an implantable cardioverter defibrillator (ICD) if indicated.
• Provide genetic counseling if a hereditary component is suspected, as HCM is commonly familial.

✘Incorrect answer options:

Congestive. Congestive heart failure is a syndrome rather than a type of cardiomyopathy. It can occur as a result of various types of cardiomyopathy, including dilated or hypertrophic, but it does not specifically describe thickened septum involvement.

Dilated. Dilated cardiomyopathy is characterized by an enlarged ventricular chamber and systolic dysfunction, not by septal thickening. It involves weakened heart muscle and reduced contractility but does not involve outflow obstruction or myocyte disarray.

Restrictive. Restrictive cardiomyopathy is associated with stiff, non-compliant ventricles that impair diastolic filling, but it is not characterized by septal hypertrophy. It is often caused by conditions like amyloidosis or fibrosis that lead to stiff myocardial tissue without septal involvement.

EXPLANATION

✔Correct answer:

Digoxin (Lanoxin). Digoxin is a cardiac glycoside that is commonly used in the acute and chronic management of heart failure to improve the heart's contractility and control symptoms. It works by increasing the force of myocardial contraction (positive inotropic effect), which enhances cardiac output and reduces symptoms of heart failure, such as fatigue and dyspnea. Digoxin also has a negative chronotropic effect, meaning it slows the heart rate, which is particularly beneficial in clients with heart failure complicated by atrial fibrillation.

Digoxin is especially helpful for clients with reduced ejection fraction (HFrEF) and persistent symptoms despite optimal use of other medications, such as ACE inhibitors and beta-blockers.

In heart failure, the heart’s ability to pump blood effectively is impaired, leading to symptoms of fluid overload, poor perfusion, and pulmonary congestion. By improving contractility, digoxin helps to restore hemodynamic balance, reduce heart failure symptoms, and improve quality of life.

Think of the heart as a struggling pump that is unable to push water effectively. Digoxin acts like an engine booster, helping the pump push more water with each stroke, improving its efficiency.

When administering digoxin, careful monitoring is essential to prevent toxicity and ensure therapeutic effectiveness.

• Monitor for signs of digoxin toxicity, such as nausea, vomiting, visual disturbances (e.g., yellow-green halos), bradycardia, and arrhythmias.
• Assess apical pulse for 1 full minute before administration. Hold the medication and notify the healthcare provider if the heart rate is:
  • Less than 60 beats per minute in adults.
  • Less than 70 beats per minute in children.
• Monitor serum digoxin levels to ensure they remain within the therapeutic range (0.8–2.0 ng/mL).
• Assess potassium levels, as hypokalemia increases the risk of digoxin toxicity.
• Educate the client about digoxin use, the importance of adherence, and recognizing signs of toxicity or worsening heart failure.

✘Incorrect answer options:

Diltiazem (Cardizem). Diltiazem is a calcium channel blocker used to manage arrhythmias (e.g., atrial fibrillation) and hypertension by reducing heart rate and myocardial workload. However, it is not used to improve contractility and is generally avoided in heart failure due to its negative inotropic effects (decreasing the strength of myocardial contraction).

Propranolol (Inderal). Propranolol is a non-selective beta-blocker that reduces heart rate and myocardial oxygen demand. While beta-blockers are used in heart failure, propranolol is less commonly prescribed due to its non-selective nature, which can exacerbate bronchoconstriction in clients with respiratory comorbidities. It does not directly enhance contractility.

Metoprolol (Lopressor). Metoprolol, a cardio-selective beta-blocker, is a cornerstone of heart failure management. However, its primary role is to reduce heart rate and myocardial oxygen demand, not to directly increase contractility. In acute heart failure exacerbations, beta-blockers are typically withheld if the client is unstable.

EXPLANATION

✔Correct answer:

Reversal of ischemia. The primary treatment goal for angina is the reversal of ischemia, which is the underlying cause of the chest pain. Myocardial ischemia occurs when the oxygen supply to the heart muscle is insufficient to meet its demand, often due to atherosclerosis in the coronary arteries. Reversing ischemia involves restoring the balance between oxygen supply and demand. This can be achieved by improving coronary blood flow, reducing myocardial oxygen demand, or both. Reversing ischemia not only relieves angina symptoms but also prevents complications such as myocardial infarction (MI) or arrhythmias.

In angina, ischemia causes transient chest pain without myocardial necrosis. If untreated, ischemia can progress to infarction, where heart muscle tissue becomes permanently damaged. Interventions, such as administering nitroglycerin to dilate coronary arteries or beta-blockers to reduce heart rate and myocardial workload, are aimed at improving blood flow and oxygenation to prevent this progression.

Think of the heart as an engine that overheats (ischemia) because it's not getting enough coolant (oxygen-rich blood). The goal is to cool the engine down by restoring the coolant supply or reducing the workload, preventing permanent damage (infarction).

Nurses play a crucial role in the management of ischemia by promptly identifying symptoms, administering appropriate medications, and educating clients on lifestyle modifications to prevent further episodes.

• Administer prescribed medications to relieve ischemia, such as:
  • Nitroglycerin to dilate coronary arteries and improve oxygen delivery to the myocardium.
  • Beta-blockers to decrease myocardial oxygen demand by lowering heart rate and contractility.
  • Calcium channel blockers to prevent coronary artery spasm and improve blood flow.
  • Antiplatelet agents (e.g., aspirin) to prevent clot formation in narrowed coronary arteries.
• Monitor for and address signs of worsening ischemia, such as prolonged chest pain, ST-segment changes on ECG, or increased frequency of angina episodes.
• Encourage lifestyle modifications to prevent ischemia, including smoking cessation, a heart-healthy diet, weight management, and regular exercise.
• Teach the client to recognize early symptoms of ischemia and take nitroglycerin as prescribed, seeking immediate medical attention if chest pain persists or worsens.

✘Incorrect answer options:

Reversal of infarction. Infarction refers to permanent myocardial damage caused by prolonged ischemia, such as in a myocardial infarction (heart attack). While the goal of angina treatment is to prevent infarction, once infarction has occurred, the damage is irreversible, and treatment focuses on limiting further injury.

Reduction of stress and anxiety. While reducing stress and anxiety can help prevent angina episodes, it is not the primary goal of treatment. Addressing the underlying ischemia is the main focus to prevent myocardial damage.

Reduction of associated risk factors. Reducing risk factors (e.g., hypertension, hyperlipidemia, smoking) is essential for long-term management and prevention of angina and coronary artery disease, but it is a secondary goal. The immediate priority is to reverse ischemia and relieve chest pain.

EXPLANATION

✔Correct answer:

Erythema marginatum, subcutaneous nodules, and fever. Rheumatic fever is an inflammatory disease that develops as a complication of untreated or poorly treated group A beta-hemolytic streptococcal (GABHS) pharyngitis (strep throat). The diagnosis is based on the Jones Criteria, which include major and minor clinical findings. Among the major criteria are:

• Erythema marginatum: A distinctive, non-itchy, pink rash with a ring or margin-like appearance, often on the trunk or proximal limbs.
• Subcutaneous nodules: Small, painless lumps located over bony prominences or tendons.
• Fever: A systemic inflammatory response is part of the minor criteria.

These signs, combined with evidence of a preceding streptococcal infection, strongly support the diagnosis of rheumatic fever.

Rheumatic fever is an autoimmune response to untreated strep throat, where the body’s immune system mistakenly attacks heart tissues, joints, skin, and the central nervous system. This can lead to complications such as rheumatic heart disease, characterized by permanent damage to heart valves.

Think of the immune system as a watchdog that mistakenly attacks the owner’s furniture (the heart, joints, and skin) after chasing away a thief (the streptococcal infection).

Early recognition and treatment of rheumatic fever are crucial to preventing complications like valve damage.

• Assess for signs of carditis, such as murmurs or tachycardia, which indicate inflammation of the heart structures.
• Monitor joints for swelling and tenderness, as arthritis is a common manifestation of rheumatic fever.
• Administer prescribed antibiotics (e.g., penicillin) to eradicate residual strep infection and prevent recurrence.
• Provide anti-inflammatory medications (e.g., aspirin or corticosteroids) to reduce inflammation in the heart and joints.
• Educate the client and family about the importance of completing the full antibiotic course and monitoring for recurrent sore throats.

✘Incorrect answer options:

Tachycardia, finger clubbing, and a loud S3. While tachycardia can be a sign of carditis in rheumatic fever, finger clubbing is not typically associated with this condition. Clubbing is more indicative of chronic hypoxia, such as in congenital heart disease or chronic lung disease. A loud S3 is associated with heart failure, not rheumatic fever specifically.

Dyspnea, cough, and palpitations. These symptoms are general signs of cardiac or pulmonary conditions but are non-specific to rheumatic fever. They may occur in advanced rheumatic heart disease when valve damage leads to heart failure, but they are not part of the diagnostic criteria.

Dyspnea, fatigue, and syncope. These are symptoms of heart failure or severe valvular disease but are not specific indicators of rheumatic fever. Syncope, in particular, is not a common manifestation of rheumatic fever.

EXPLANATION

✔Correct answer:

Left ventricle. Acute pulmonary edema caused by heart failure is most commonly due to left ventricular dysfunction. When the left ventricle fails to pump blood effectively (as in left-sided heart failure), blood backs up into the left atrium and then into the pulmonary veins and capillaries. This increased pressure in the pulmonary circulation forces fluid to leak into the alveoli, leading to pulmonary congestion and edema.

The left ventricle is responsible for pumping oxygenated blood from the heart into systemic circulation. In conditions like acute myocardial infarction, hypertension, or dilated cardiomyopathy, the left ventricle may fail to pump blood efficiently, causing a cascade of events:

1. Blood backs up into the pulmonary circulation, increasing pulmonary capillary hydrostatic pressure.
2. Fluid leaks from the capillaries into the alveoli, impairing gas exchange.
3. Symptoms such as severe shortness of breath, pink, frothy sputum, crackles on auscultation, and hypoxemia develop.

Think of the left ventricle as a drain that removes water (blood) from a sink (lungs). If the drain is clogged, water backs up into the sink and overflows, just as blood backs up into the pulmonary circulation, causing fluid to flood the lungs.

Immediate management is critical to improve oxygenation and relieve pulmonary congestion.

• Position the client in high Fowler’s position to improve lung expansion and reduce pulmonary congestion.
• Administer oxygen therapy or non-invasive positive pressure ventilation (e.g., CPAP) to enhance oxygenation and reduce the work of breathing.
• Administer prescribed medications to address the underlying cause:
  • Diuretics (e.g., furosemide) to reduce fluid overload and pulmonary congestion.
  • Vasodilators (e.g., nitroglycerin) to reduce preload and afterload, decreasing the workload on the left ventricle.
  • Inotropic agents (e.g., dobutamine) if necessary, to improve left ventricular contractility.
• Monitor for worsening symptoms, such as decreasing oxygen saturation, arrhythmias, or hypotension.
• Provide reassurance and emotional support, as pulmonary edema can cause significant anxiety and fear in clients.

✘Incorrect answer options:

Left atrium. While blood does back up into the left atrium in left-sided heart failure, the primary dysfunction occurs in the left ventricle. The left atrium's role is to receive blood from the pulmonary veins and pass it to the left ventricle, but it does not cause the fluid buildup in the lungs.

Right atrium. The right atrium receives blood from the systemic circulation and is not directly involved in pulmonary congestion. Dysfunction in the right atrium would cause systemic congestion, such as peripheral edema or jugular vein distention, but not pulmonary edema.

Right ventricle. Right ventricular dysfunction causes right-sided heart failure, leading to systemic venous congestion (e.g., peripheral edema, ascites, and hepatomegaly), not pulmonary congestion. However, right-sided failure can occur secondary to left-sided failure in some cases (biventricular failure).

EXPLANATION

✔Correct answer:

Impaired ventricular ejection during systole. The presence of a fourth heart sound (S4) is often an indicator of impaired ventricular compliance and suggests diastolic dysfunction. S4 occurs during late diastole, just before systole, when the atria contract to push blood into a stiff or non-compliant left ventricle. This abnormal sound is associated with conditions such as left ventricular hypertrophy due to long-standing hypertension, aortic stenosis, or other conditions that lead to reduced ventricular compliance.

S4 is caused by turbulent blood flow when the atria attempt to contract against a non-compliant ventricle. It is often described as a "Tennessee" rhythm (the sound pattern of "a-stiff-wall"), where the "a" corresponds to atrial contraction.

In hypertension or hypertrophic conditions, the left ventricle often becomes thickened (hypertrophic) due to the increased workload required to pump against elevated systemic vascular resistance. Over time, the stiffened myocardium loses its ability to relax properly during diastole, leading to impaired filling. The atria must work harder to push blood into the ventricle, creating the S4 sound.

Imagine trying to pour water (blood) into a rigid container (stiff ventricle). The container resists the flow, and when the final push comes from atrial contraction, it creates a splash (S4).

The presence of an S4 indicates underlying cardiac issues that require assessment and management. Nurses should monitor and address contributing factors, such as hypertension or ischemic heart disease.

• Monitor blood pressure closely and encourage adherence to antihypertensive medications to reduce ventricular workload.
• Assess for other symptoms of diastolic heart failure, such as dyspnea, fatigue, and signs of fluid overload (e.g., peripheral edema, pulmonary congestion).
• Encourage lifestyle changes, including a low-sodium diet, regular exercise, and weight management, to control hypertension and improve cardiac function.
• Collaborate with the healthcare provider to optimize the client’s medication regimen, which may include:
  • ACE inhibitors or ARBs to reduce afterload and promote ventricular remodeling.
  • Beta-blockers to reduce myocardial workload and improve relaxation.
  • Calcium channel blockers for their vasodilatory and cardiac relaxation effects in some cases.
• Educate the client about recognizing symptoms of worsening cardiac function, such as chest pain, shortness of breath, or exercise intolerance.

✘Incorrect answer options:

A dilated aorta. A dilated aorta is typically associated with conditions like aortic aneurysm or aortic regurgitation, which may cause systolic murmurs but are not directly linked to the presence of an S4 sound. An S4 is related to ventricular stiffness, not aortic dilation.

A normally functioning heart. The presence of an S4 is always considered abnormal. It indicates increased resistance to ventricular filling during diastole, which is not seen in a healthy, normally functioning heart.

Reduced myocardial contractility. Reduced myocardial contractility is associated with systolic heart failure, where the heart’s pumping ability is impaired. This condition is more likely to cause a third heart sound (S3) rather than an S4, which is specific to diastolic dysfunction and stiff ventricles.

EXPLANATION

✔Correct answer:

Inadequate oxygen supply to the myocardium. The primary underlying cause of angina is an inadequate oxygen supply to the myocardium (ischemia). This occurs when the oxygen demand of the heart muscle exceeds the supply provided by the coronary arteries. The imbalance is often caused by coronary artery disease (CAD), where atherosclerotic plaques narrow the coronary arteries, limiting blood flow. Other factors, such as coronary artery spasm or increased myocardial oxygen demand (e.g., during exercise or stress), can also contribute to this mismatch.

The heart requires a continuous supply of oxygen-rich blood to meet its metabolic demands, especially during periods of increased activity. In angina, ischemia triggers pain receptors, resulting in chest pain or discomfort. Types of angina include:

• Stable angina: Predictable chest pain during exertion, caused by fixed atherosclerotic plaques.
• Unstable angina: Unpredictable chest pain at rest, caused by plaque rupture or thrombus formation.
• Variant angina (Prinzmetal's angina): Chest pain due to coronary artery spasm, typically occurring at rest.

The hallmark symptom of myocardial ischemia is chest pain, often described as a squeezing, pressure-like sensation that may radiate to the arms, neck, jaw, or back.

Imagine the heart as a factory that constantly needs fuel (oxygen) to keep running. The coronary arteries act like pipelines delivering this fuel. If the pipelines are narrowed or partially blocked (like a clogged pipe), the factory can't get enough fuel during peak demand (exercise or stress), causing it to slow down and trigger a warning signal (angina). Rest or medications like nitroglycerin open the pipeline slightly, allowing enough fuel to flow again and relieving the symptoms.

The management of angina focuses on restoring the balance between oxygen supply and demand and preventing progression to myocardial infarction.

• Administer prescribed medications to improve oxygen supply or reduce oxygen demand, such as:
  • Nitroglycerin to dilate coronary arteries and relieve acute chest pain.
  • Beta-blockers to lower heart rate and myocardial oxygen demand.
  • Calcium channel blockers to prevent coronary artery spasm and improve blood flow.
  • Antiplatelet agents (e.g., aspirin) to prevent thrombus formation.
  • Statins to reduce cholesterol levels and slow the progression of atherosclerosis.
• Encourage the client to avoid triggers, such as overexertion, cold weather, or emotional stress, that may increase oxygen demand.
• Educate the client on recognizing early warning signs of worsening ischemia (e.g., chest pain lasting >20 minutes) and seeking immediate medical attention.
• Monitor for changes in vital signs, such as tachycardia or hypotension, which may indicate worsening ischemia or complications.
• Promote lifestyle modifications, such as smoking cessation, maintaining a healthy diet, regular exercise, and managing comorbid conditions (e.g., hypertension or diabetes).

✘Incorrect answer options:

Increased preload. While increased preload (the amount of blood filling the ventricles before contraction) can increase myocardial workload and oxygen demand, it is not the primary cause of angina. Angina is specifically caused by inadequate oxygen supply, not increased preload alone.

Decreased afterload. Decreased afterload (the resistance the heart must pump against) reduces myocardial workload and oxygen demand, which would actually improve, not worsen, angina. This choice does not explain the mechanism of myocardial ischemia.

Coronary artery spasm. Coronary artery spasm can cause variant angina (Prinzmetal’s angina) but is not the most common cause of angina overall. The majority of angina cases are due to coronary artery disease and the resulting imbalance between oxygen supply and demand.

EXPLANATION

✔Correct answer:

Dilated. The type of cardiomyopathy commonly associated with the postpartum period is a form of dilated cardiomyopathy known as peripartum cardiomyopathy (PPCM). This condition occurs in the last month of pregnancy or within five months after delivery. PPCM is characterized by a weakening and dilation of the left ventricle, leading to impaired contractility and heart failure symptoms. Although the exact cause is not fully understood, it is thought to involve a combination of hormonal changes, immune responses, inflammation, and cardiovascular stress during pregnancy.

In peripartum cardiomyopathy, the heart's ability to pump blood is reduced due to ventricular dilation and systolic dysfunction (ejection fraction <45%). This leads to signs and symptoms of heart failure, such as dyspnea, fatigue, peripheral edema, pulmonary congestion, and decreased exercise tolerance. PPCM may also cause tachycardia and thromboembolic complications (e.g., blood clots) due to stasis of blood in the dilated ventricle.

Imagine the heart as a balloon. During pregnancy, the body places extra stress on the balloon, causing it to stretch (dilate) and weaken. After delivery, the balloon struggles to return to its normal size and function, leading to symptoms like fatigue and fluid buildup.

The management of peripartum cardiomyopathy focuses on relieving symptoms, improving cardiac function, and preventing complications like arrhythmias or thromboembolism.

• Monitor the client closely for symptoms of heart failure, including dyspnea, fatigue, and fluid retention.
• Administer medications as prescribed, such as:
  • Diuretics to reduce fluid overload.
  • Beta-blockers to reduce cardiac workload and control heart rate.
  • ACE inhibitors or angiotensin receptor blockers (ARBs) (postpartum only) to improve ventricular function.
  • Anticoagulants to prevent thromboembolism, especially in cases of severe ventricular dysfunction.
• Encourage the client to rest and limit physical activity to reduce cardiac stress.
• Provide education on recognizing signs of worsening heart failure, such as increasing shortness of breath, weight gain, or palpitations.
• Discuss family planning, as subsequent pregnancies can significantly increase the risk of recurrence or worsening cardiomyopathy.

✘Incorrect answer options:

Hypertrophic. Hypertrophic cardiomyopathy involves abnormal thickening of the myocardium, usually of genetic origin. It is not specifically associated with the postpartum period or pregnancy. Symptoms often include chest pain, syncope, and arrhythmias but are unrelated to peripartum heart failure.

Myocarditis. Myocarditis refers to inflammation of the myocardium, often caused by infections or autoimmune reactions. While myocarditis can cause heart failure, it is not uniquely associated with the postpartum period or pregnancy.

Restrictive. Restrictive cardiomyopathy involves stiffening of the heart muscle, leading to impaired ventricular filling. This type of cardiomyopathy is rare and is more commonly associated with conditions such as amyloidosis or sarcoidosis, rather than pregnancy or the postpartum period.

EXPLANATION

✔Correct answer:

Oliguria. Oliguria, or decreased urine output, is a common symptom associated with right-sided heart failure, especially as the condition progresses. In heart failure, reduced cardiac output leads to decreased renal perfusion. When the kidneys receive insufficient blood flow, the glomerular filtration rate (GFR) decreases, resulting in reduced urine production. Additionally, right-sided heart failure is characterized by fluid retention and systemic venous congestion, which further exacerbates oliguria.

In right-sided heart failure, the right ventricle cannot effectively pump blood into the pulmonary circulation, causing blood to back up into the systemic venous system. This venous congestion reduces the amount of blood reaching the kidneys, leading to impaired filtration and oliguria. The renin-angiotensin-aldosterone system (RAAS) is activated in response to perceived hypoperfusion, promoting sodium and water retention, which further limits urine output.

Imagine the kidneys as filters in a factory. If the delivery truck (blood flow) bringing raw materials slows down, the filters cannot process enough material (urine), leading to a reduced output.

Oliguria in right-sided heart failure requires careful monitoring and intervention to prevent complications related to fluid overload and inadequate renal perfusion.

• Monitor urine output closely, documenting hourly and total outputs to identify trends.
• Assess for additional signs of fluid retention, such as peripheral edema, weight gain, and jugular vein distention.
• Administer prescribed diuretics, such as furosemide, to reduce fluid overload and improve renal perfusion.
• Monitor renal function tests (BUN, creatinine) and electrolyte levels to detect early signs of kidney injury or imbalance.
• Educate the patient on the importance of adhering to a low-sodium diet and fluid restrictions to minimize fluid retention.

✘Incorrect answer options:

Adequate urine output. Adequate urine output is not characteristic of right-sided heart failure. Decreased renal perfusion and fluid retention are hallmarks of the condition, typically resulting in oliguria rather than normal or adequate urine output.

Polyuria. Polyuria, or excessive urine output, is not typically associated with right-sided heart failure. It may be seen in conditions such as diabetes mellitus, diabetes insipidus, or diuretic use, but in the context of heart failure, the kidneys are more likely to conserve fluid due to reduced perfusion.

Polydipsia. Polydipsia, or excessive thirst, is not directly related to right-sided heart failure. It is more commonly associated with conditions like diabetes mellitus or dehydration, where increased thirst is a compensatory response to fluid loss or hyperosmolarity.

EXPLANATION

✔Correct answer:

It can develop into ventricular fibrillation at any time. Ventricular tachycardia (VT) is a life-threatening dysrhythmia originating in the ventricles. It is characterized by a rapid ventricular rate (greater than 100 beats per minute), wide QRS complexes, and a lack of organized atrial activity. The nurse's primary concern with VT is that it can deteriorate into ventricular fibrillation (VF), a chaotic rhythm that leads to the cessation of cardiac output and sudden cardiac arrest.

VT often compromises cardiac output because the rapid rate prevents the ventricles from adequately filling with blood, reducing stroke volume and overall perfusion to vital organs. This reduced perfusion can cause myocardial ischemia, cerebral hypoxia, and organ failure. If untreated, VT can escalate into VF, where the ventricles quiver ineffectively, leading to a complete loss of pulse. Therefore, VT requires immediate recognition and intervention to prevent VF and sudden death.

Pathophysiology of VT:  

VT occurs when an ectopic focus in the ventricles initiates and sustains rapid electrical impulses, overriding the heart's normal pacemaker (the sinoatrial node). This rapid, disorganized electrical activity disrupts normal ventricular contraction and reduces cardiac output. If VT progresses to VF, electrical chaos completely stops the heart's pumping ability.

Think of the heart as a water pump. In VT, the pump works too quickly, pushing out less water (blood) with each stroke. If the pump breaks down entirely (as in VF), no water (blood) flows at all, causing a complete shutdown of the system.

When VT is identified, the nurse must act promptly to manage the rhythm and prevent further complications:

• Assess the client immediately: Check for a pulse. VT can occur with or without a pulse (pulseless VT requires immediate CPR and defibrillation).
• Monitor symptoms: Look for signs of reduced cardiac output, such as hypotension, chest pain, shortness of breath, or decreased level of consciousness.
• Administer medications as prescribed: Antiarrhythmic drugs like amiodarone, lidocaine, or procainamide may be used to stabilize the rhythm.
• Prepare for defibrillation or cardioversion: If the client is unstable (e.g., low blood pressure, altered mental status), synchronized cardioversion may be necessary to restore a normal rhythm.
• Call for emergency help: VT is a medical emergency, particularly if the client becomes pulseless or unstable.
• Address underlying causes: Correct electrolyte imbalances (e.g., hypokalemia or hypomagnesemia), manage ischemia, or treat any contributing conditions like hypoxia.

✘Incorrect answer options:

It is uncomfortable for the client, giving a sense of impending doom: While some clients with VT may feel anxious or report a sense of impending doom, this is not the primary concern. The nurse's priority is to address the risk of VT progressing to VF, which is far more critical than discomfort.

It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia: VT does not produce high cardiac output. Instead, it leads to reduced cardiac output due to inadequate ventricular filling time. This results in poor perfusion, including cerebral and myocardial ischemia, but this is a consequence of low, not high, cardiac output.

It is almost impossible to convert to a normal sinus rhythm: VT can often be successfully treated and converted back to sinus rhythm through interventions such as antiarrhythmic medications, cardioversion, or defibrillation. Early recognition and treatment are crucial for successful management.

EXPLANATION

✔Correct answer:

12-lead electrocardiogram (ECG). A 12-lead electrocardiogram (ECG) is the most commonly used diagnostic test for angina. This non-invasive test records the heart's electrical activity and helps detect changes consistent with myocardial ischemia, the primary cause of angina. During an episode of angina, the ECG may show ST-segment depression, T-wave inversion, or other signs of ischemia, particularly if performed while the client is experiencing symptoms or during a stress test. An ECG is a first-line, quick, and cost-effective tool for diagnosing angina and distinguishing it from other causes of chest pain, such as myocardial infarction or arrhythmias.

Angina occurs when there is a mismatch between myocardial oxygen supply and demand, often due to coronary artery disease. This ischemia can alter the heart's electrical conduction, resulting in the characteristic ECG changes seen during an anginal episode. However, in stable angina, the ECG may appear normal at rest, making stress testing an important adjunct.

Think of the ECG as a snapshot of the heart's electrical system. Just like a camera captures a clear image of what's happening in a moment, the ECG captures electrical patterns that can reveal if the heart is struggling during periods of ischemia.

Nurses play a critical role in preparing the client for an ECG and interpreting the results in collaboration with the healthcare provider.

• Ensure the client is lying still and relaxed during the test to minimize interference or artifact on the ECG recording.
• Observe for acute changes on the ECG, such as ST-segment depression or elevation, and notify the healthcare provider promptly if detected.
• Explain the procedure to the client, emphasizing that it is painless and takes only a few minutes.
• If symptoms are exercise-induced, prepare the client for a stress ECG, which involves monitoring the heart during physical exertion or pharmacologic stimulation.
• Monitor the client closely for chest pain or other symptoms during or after the test, especially if they are undergoing a stress test.

✘Incorrect answer options:

Chest X-ray. A chest X-ray is useful for evaluating lung fields, the size and shape of the heart, and ruling out other causes of chest pain, such as pneumonia or aortic aneurysm. However, it is not diagnostic for angina or ischemia.

Echocardiogram. An echocardiogram uses ultrasound to visualize the heart's structure and function. While it can identify wall motion abnormalities during ischemia or infarction, it is not the primary test for diagnosing angina. It is often used in conjunction with other tests, such as a stress ECG.

Cardiac catheterization. Cardiac catheterization is a more invasive test used to visualize the coronary arteries and confirm the presence of significant blockages. While it is the gold standard for diagnosing coronary artery disease, it is not the first-line test for angina due to its invasiveness and associated risks.

EXPLANATION

✔Correct answer:

Right-sided heart failure. The symptoms of weight gain, persistent nausea, reduced urine output, and fluid retention are classic signs of right-sided heart failure. In right-sided heart failure, the right ventricle fails to effectively pump blood into the pulmonary circulation, leading to a backup of blood in the systemic venous circulation. This backup results in systemic congestion and fluid retention, which manifest as peripheral edema, ascites, hepatomegaly, jugular vein distention (JVD), and reduced urine output (oliguria). Persistent nausea is often related to hepatic congestion or ascites compressing the stomach, causing gastrointestinal discomfort.

When the right ventricle cannot adequately pump blood, venous return to the heart is impeded, leading to increased venous pressure. This elevated pressure causes fluid to leak into interstitial spaces, resulting in peripheral edema and ascites. The reduced renal perfusion triggers activation of the renin-angiotensin-aldosterone system (RAAS), leading to sodium and water retention, further worsening systemic congestion and reducing urine output.

Think of the right side of the heart as a delivery truck that picks up packages (blood) from the body and takes them to the lungs. If the truck is broken or overloaded, the packages pile up at the pickup points (veins and tissues), leading to swelling (edema) and congestion in the body.

Management of right-sided heart failure focuses on relieving symptoms, improving cardiac output, and reducing fluid overload.

• Monitor for signs of systemic fluid retention, including peripheral edema, weight gain, and decreased urine output.
• Assess for JVD and hepatomegaly during physical examinations to confirm systemic venous congestion.
• Administer prescribed diuretics, such as furosemide, to reduce fluid retention and relieve symptoms of congestion.
• Encourage adherence to a low-sodium diet to minimize fluid retention.
• Monitor electrolyte levels, renal function, and daily weights to evaluate fluid balance and detect worsening symptoms early.
• Educate the client about recognizing early signs of fluid overload and the importance of medication adherence.

✘Incorrect answer options:

Angina pectoris. Angina pectoris is characterized by chest pain due to myocardial ischemia but is not associated with fluid retention, systemic congestion, or weight gain. It results from inadequate oxygen supply to the heart muscle and does not directly affect systemic fluid balance.

Cardiomyopathy. Cardiomyopathy refers to diseases of the heart muscle, which may cause symptoms of heart failure. However, it is a general condition and does not specifically explain the systemic congestion and fluid retention seen in right-sided heart failure unless it leads to ventricular dysfunction.

Left-sided heart failure. Left-sided heart failure primarily causes pulmonary congestion rather than systemic congestion. Symptoms include dyspnea, orthopnea, crackles on auscultation, and reduced oxygenation, but it does not typically result in peripheral edema, ascites, or hepatic congestion.

EXPLANATION

✔Correct answer:

Tachycardia. Tachycardia, or an increased heart rate, is a key effect of sympathetic nervous system (SNS) stimulation, which is part of the "fight or flight" response. When the SNS is activated, it releases neurotransmitters such as epinephrine and norepinephrine, which bind to beta-adrenergic receptors in the heart. This results in an increased heart rate (tachycardia) and enhanced myocardial contractility to prepare the body to respond to stress or danger. These changes help the body deliver oxygen and nutrients to tissues more quickly during times of physical or emotional stress.

The sympathetic nervous system is a branch of the autonomic nervous system responsible for involuntary responses to stress. Upon activation, it stimulates the adrenal glands to release catecholamines, which act on various organs. In the heart, beta-1 adrenergic receptor activation increases the firing rate of the sinoatrial (SA) node, accelerates conduction through the atrioventricular (AV) node, and strengthens ventricular contractions, leading to tachycardia and increased cardiac output.

Think of the SNS as pressing the gas pedal in a car to accelerate. When you're faced with danger or stress, the body "steps on the gas," causing the heart to beat faster (tachycardia) to provide the necessary fuel (oxygenated blood) to the muscles and brain.

Understanding the effects of SNS stimulation helps nurses explain stress-related symptoms and guide clients in managing anxiety through relaxation techniques or medications that counteract SNS overactivity.

• Educate clients about the normal "fight or flight" response and how it leads to symptoms like a racing heart, increased breathing rate, and sweating during anxiety episodes.
• Monitor vital signs, particularly heart rate and blood pressure, in clients experiencing acute stress or anxiety.
• Provide or suggest relaxation techniques, such as deep breathing, progressive muscle relaxation, or mindfulness, to reduce SNS activation.
• If prescribed, administer beta-blockers (e.g., propranolol) to block SNS effects in clients with severe tachycardia or anxiety.
• Encourage lifestyle modifications, such as regular exercise and adequate sleep, to manage chronic stress and reduce SNS overactivity.

✘Incorrect answer options:

Bradycardia. Bradycardia, or a slow heart rate, is associated with parasympathetic nervous system (PNS) activity, not SNS stimulation. The PNS slows the heart rate via the vagus nerve, promoting "rest and digest" functions.

Hypotension. Hypotension, or low blood pressure, is the opposite of what occurs during SNS activation. The SNS causes vasoconstriction, which increases blood pressure to ensure adequate blood flow to vital organs.

Decreased myocardial contractility. The SNS increases myocardial contractility, not decreases it. Enhanced contractility allows the heart to pump blood more forcefully, increasing cardiac output during stress or danger.

EXPLANATION

✔Correct answer:

Left ventricular enlargement. When the apical pulse (also known as the point of maximal impulse or PMI) is displaced downward and laterally from its normal location at the 5th intercostal space at the midclavicular line, it is often indicative of left ventricular enlargement (LVE). This occurs when the left ventricle hypertrophies or dilates due to increased workload, which can result from conditions such as chronic hypertension, aortic stenosis, or heart failure. The enlargement causes the left ventricle to push against the chest wall in a different location.

The left ventricle, responsible for pumping oxygenated blood to the systemic circulation, can enlarge in response to increased resistance or volume overload. This enlargement shifts the heart's position within the thoracic cavity, causing the PMI to move downward (toward the diaphragm) and laterally (closer to the anterior axillary line).

Imagine a balloon being inflated inside a box. As the balloon gets larger, it shifts position and presses against different parts of the box. Similarly, when the left ventricle enlarges, it shifts and presses against a different area of the chest wall, causing the apical pulse to move.

The displacement of the apical pulse is a clinical finding that warrants further investigation to identify the underlying cause of left ventricular enlargement and guide treatment.

• Document the location of the displaced apical pulse and assess for associated symptoms, such as shortness of breath, fatigue, or chest pain.
• Perform or request diagnostic tests, such as an echocardiogram, to confirm left ventricular enlargement and assess cardiac function.
• Monitor the client for signs of heart failure or complications, including peripheral edema or pulmonary congestion.
• Collaborate with the healthcare provider to address underlying causes, such as hypertension or valve disorders.
• Educate the client about lifestyle modifications and treatment options to reduce the cardiac workload, such as sodium restriction or prescribed medications.

✘Incorrect answer options:

Left atrial enlargement. Left atrial enlargement (LAE) does not typically cause displacement of the apical pulse. Instead, LAE may manifest as signs such as atrial fibrillation or changes on an electrocardiogram (e.g., a wide P wave in lead II). The left atrium is located posteriorly and does not significantly affect the location of the apical pulse.

Right atrial enlargement. Right atrial enlargement (RAE) also does not cause apical pulse displacement. Instead, it might present as distended neck veins or signs of right-sided heart failure. Like the left atrium, the right atrium is more central and posterior in location.

Right ventricular enlargement. Right ventricular enlargement (RVE) may cause a different clinical finding, such as a prominent or sustained parasternal heave felt along the left sternal border. It does not typically cause the apical pulse to shift downward and laterally, as the right ventricle is situated more anteriorly and inferiorly than the left ventricle.

EXPLANATION

✔Correct answer:

Variant angina.  The client's description of chest pain occurring at the same time every morning and without exertion or other triggers is characteristic of variant angina, also known as Prinzmetal's angina. This type of angina is caused by vasospasm of the coronary arteries, which temporarily reduces blood flow to the myocardium, leading to chest pain. Unlike stable angina, which is triggered by physical exertion or stress, variant angina often occurs at rest, follows a predictable pattern, and tends to happen at the same time of day or night.

Pathophysiology of Variant Angina:  

• Coronary vasospasm causes a temporary, reversible narrowing of the coronary arteries, reducing blood flow and oxygen supply to the heart muscle.
• Variant angina is usually associated with transient ST-segment elevation on an ECG during episodes, which resolves when the pain subsides.
• It is unrelated to fixed coronary artery blockages (as seen in stable angina) but may coexist with atherosclerosis.

Imagine a garden hose supplying water to plants (heart tissue). In stable angina, the hose is partially blocked (atherosclerosis), but in variant angina, someone briefly pinches the hose shut (vasospasm), stopping water flow for a short time.

The nurse's role includes identifying and managing symptoms of variant angina while educating the client about preventing episodes and recognizing signs of worsening cardiac health.

• Administer prescribed medications: Calcium channel blockers (e.g., amlodipine) and nitrates (e.g., nitroglycerin) are commonly used to prevent and relieve coronary artery spasms.
• Assess for triggers: Some clients may have triggers such as smoking, cold weather, stress, or certain medications (e.g., stimulants). Advise clients to avoid or minimize exposure to these triggers.
• Monitor cardiac status: Obtain a 12-lead ECG during chest pain episodes to assess for transient ST-segment elevation and rule out myocardial infarction (MI). Continuous monitoring may be necessary in hospitalized clients.
• Provide education: Teach clients how to recognize angina symptoms, use prescribed sublingual nitroglycerin, and seek immediate medical attention if symptoms worsen or do not resolve.
• Collaborate with healthcare providers: Variant angina may require further testing, such as coronary angiography, to confirm the diagnosis and rule out other causes of chest pain.

✘Incorrect answer options:

Stable angina: Stable angina occurs due to physical exertion, emotional stress, or other predictable triggers. The pain resolves with rest or nitroglycerin. Since the client's chest pain occurs at rest and follows a specific time-based pattern, it does not align with stable angina.

Unstable angina: Unstable angina is unpredictable and occurs at rest or with minimal exertion, often signifying a worsening of coronary artery disease. It is more likely to lead to myocardial infarction and requires urgent medical attention. However, unlike variant angina, unstable angina does not typically follow a regular time pattern or involve coronary artery spasms.

Nonanginal pain: Nonanginal pain refers to chest pain not caused by myocardial ischemia, such as musculoskeletal pain or gastrointestinal issues (e.g., GERD). The client’s symptoms of severe chest pain and timing suggest ischemic etiology, ruling out nonanginal pain.

EXPLANATION

✔Correct answer:

Activity intolerance related to pump failure. The priority nursing diagnosis in this scenario is "Activity intolerance related to pump failure" because it directly addresses the client’s decreased cardiac output and its impact on oxygen delivery to tissues. Clients with heart failure and pulmonary edema are often unable to tolerate activity due to the heart's inability to meet the metabolic demands of the body, leading to fatigue and respiratory distress. In this case, the client’s severe respiratory distress indicates an urgent need to manage the underlying pump failure to improve oxygenation and relieve symptoms.

Heart failure results in the inability of the heart to effectively pump blood, leading to fluid backup in the lungs (pulmonary edema). This fluid interferes with gas exchange, resulting in hypoxemia and respiratory distress. Activity intolerance occurs when the body cannot maintain sufficient cardiac output during physical exertion due to pump failure. Resolving this issue is critical for improving the client's quality of life and overall functionality.

Imagine the heart as a water pump supplying water to all areas of a house. If the pump is weak (heart failure), it can't supply enough water (blood and oxygen) to meet the demand when extra faucets are turned on (activity). This results in reduced function and strain on the system, similar to how the body feels during activity when the heart is not functioning properly.

Addressing activity intolerance requires interventions that focus on optimizing oxygenation, reducing the workload on the heart, and promoting adequate rest. These interventions should prioritize stabilizing the client's respiratory and cardiovascular status.

• Position the client in high Fowler's position to promote lung expansion and improve oxygenation.
• Administer oxygen therapy as prescribed to alleviate hypoxemia.
• Administer diuretics or other medications as prescribed to reduce pulmonary congestion and improve cardiac output.
• Encourage energy conservation techniques, such as clustering care and avoiding unnecessary exertion.
• Monitor vital signs, including oxygen saturation and heart rate, to assess the client’s response to interventions.

✘Incorrect answer options:

Risk for infection related to stasis of alveolar secretions. While infection risk is an important consideration for clients with pulmonary edema, it is not the most urgent concern in this case. Severe respiratory distress requires immediate attention, as it can quickly lead to hypoxemia and respiratory failure if not addressed.

Impaired skin integrity related to pressure. Impaired skin integrity is a valid concern for clients who are immobile or experiencing edema. However, it does not take priority over the client's respiratory distress and cardiac dysfunction, which are life-threatening if left unaddressed.

Constipation related to immobility. Constipation may occur in clients with heart failure due to immobility or medication use (e.g., diuretics). However, it is a lower-priority diagnosis compared to the client’s impaired oxygenation and cardiac output.

EXPLANATION

✔Correct answer:

Potassium level. Before administering furosemide (Lasix) and initiating digoxin (Lanoxin), the nurse must check the client's potassium level because low potassium (hypokalemia) increases the risk of digoxin toxicity. Furosemide, a loop diuretic, causes significant potassium loss through its action on the renal tubules, which can predispose the client to hypokalemia. Digoxin has a narrow therapeutic range, and hypokalemia can sensitize the heart to digoxin's effects, leading to serious complications such as arrhythmias.

Potassium is an essential electrolyte for maintaining normal cardiac function. Digoxin works by inhibiting the sodium-potassium ATPase pump, which increases intracellular calcium in myocardial cells, enhancing contractility. However, when potassium levels are low, digoxin binds more readily to the pump, amplifying its effects and increasing the risk of toxicity. This can manifest as symptoms like nausea, vomiting, visual disturbances (yellow-green halos), and life-threatening cardiac arrhythmias.

Imagine potassium as a "safety barrier" that keeps digoxin's effects under control. If the barrier is too low (hypokalemia), digoxin becomes overactive, like a car speeding out of control on a slippery road, leading to potential crashes (toxicity).

When administering furosemide and digoxin, nurses should take precautions to prevent electrolyte imbalances and digoxin toxicity.

• Check potassium levels before administering furosemide and digoxin; normal levels range between 3.5–5.0 mEq/L.
• Monitor for signs of hypokalemia, such as muscle weakness, cramping, and cardiac arrhythmias.
• Administer potassium supplements or potassium-sparing medications as prescribed if potassium is low.
• Assess the client for signs of digoxin toxicity, including nausea, vomiting, bradycardia, or visual changes.
• Monitor daily weights and intake/output to assess for fluid balance and diuretic efficacy.

✘Incorrect answer options:

Digoxin level: While digoxin levels are important to monitor, checking potassium levels is a higher priority in this case because furosemide increases the risk of hypokalemia, which can precipitate digoxin toxicity. Digoxin levels are typically checked after the medication is initiated or if toxicity is suspected.

Sodium level: Furosemide can cause hyponatremia, but sodium levels do not directly influence digoxin toxicity, making this option less critical in this situation. Monitoring sodium is important for overall fluid and electrolyte balance but not the primary concern before administering these medications.

Creatinine level: While creatinine levels indicate kidney function and are important when administering furosemide (since it is excreted by the kidneys) or digoxin (which can accumulate in renal impairment), potassium levels have a more immediate impact on cardiac function and digoxin safety in this context.

EXPLANATION

✔Correct answer:

Preload, afterload, contractility, and heart rate. Myocardial oxygen demand (MVO2) is influenced by factors that increase the workload of the heart. These factors include preload, afterload, contractility, and heart rate. When any of these parameters increases, the heart must work harder, leading to greater oxygen consumption by the myocardium.

1. Preload: Refers to the volume of blood returning to the heart and stretching the ventricles before contraction. An increase in preload means the heart must pump a larger volume of blood, increasing oxygen demand.
2. Afterload: Refers to the resistance the heart must pump against to eject blood during systole. Higher afterload, as seen in hypertension, increases the workload of the heart and oxygen demand.
3. Contractility: Refers to the strength of the heart's contraction. Increased contractility requires more energy and oxygen.
4. Heart rate: A faster heart rate increases the number of contractions per minute, reducing diastolic filling time (when coronary arteries receive oxygenated blood) and simultaneously increasing oxygen consumption.

Imagine the heart as a car engine. Preload is the weight loaded into the car, afterload is the steepness of the hill the car has to climb, contractility is how hard the engine has to work to move, and heart rate is how fast the car is running. The more these factors increase, the more fuel (oxygen) the engine (heart) consumes.

Managing these factors is critical for reducing myocardial oxygen demand and preventing ischemia, particularly in clients recovering from cardiac events.

• Monitor preload: Use diuretics, as prescribed, to reduce fluid volume and preload in cases of fluid overload or heart failure.
• Manage afterload: Administer antihypertensive medications, such as ACE inhibitors or vasodilators, to reduce systemic vascular resistance and afterload.
• Control contractility: Use beta-blockers or calcium channel blockers to decrease excessive myocardial contractility and workload.
• Regulate heart rate: Administer beta-blockers to slow the heart rate, improving diastolic filling time and reducing oxygen demand.
• Educate the client on lifestyle changes, such as avoiding overexertion and managing stress, to prevent increases in myocardial workload.

✘Incorrect answer options:

Preload, afterload, and cerebral blood flow. While preload and afterload do influence myocardial oxygen demand, cerebral blood flow does not directly affect cardiac oxygen consumption. Cerebral blood flow is regulated by its own unique mechanisms unrelated to myocardial workload.

Preload, afterload, and renal blood flow. Similar to cerebral blood flow, renal blood flow is not a determinant of myocardial oxygen demand. While the kidneys are important in regulating blood pressure and fluid balance, they do not directly affect oxygen consumption by the myocardium.

Preload, afterload, cerebral blood flow, and heart rate. This option incorrectly includes cerebral blood flow, which is not a factor influencing myocardial oxygen demand. Contractility, a key determinant, is missing in this option.

EXPLANATION

✔Correct answer:

Help the client sit down. The nurse's first priority when a client reports chest pain during activity is to help the client sit down and rest. Chest pain during physical activity is commonly caused by myocardial ischemia, which occurs when the heart's oxygen demand exceeds the supply. Sitting down reduces myocardial oxygen demand by decreasing physical exertion and workload on the heart. This action helps prevent the situation from worsening and allows the nurse to assess the client's condition safely.

Angina occurs when the oxygen supply to the heart is temporarily insufficient. Stopping physical activity helps restore the balance between oxygen supply and demand. If the ischemia progresses without intervention, it could lead to more severe complications such as myocardial infarction (MI). Ensuring the client is in a safe, resting position also minimizes the risk of injury in case of dizziness or syncope.

Imagine an overheated engine while driving uphill. The first step is to stop the car and let the engine rest before trying to cool it down further or take additional steps to address the issue.

After the client is seated safely, the nurse should proceed with further actions to assess and manage the chest pain.

• Assess the client's vital signs and pain characteristics (e.g., location, intensity, duration, and associated symptoms like shortness of breath or nausea).
• Administer sublingual nitroglycerin, as prescribed, to relieve ischemia if the client has no contraindications (e.g., hypotension).
• Obtain a 12-lead ECG to evaluate for signs of ischemia or other abnormalities.
• Notify the healthcare provider if the chest pain persists or worsens despite interventions.
• Provide emotional reassurance and monitor for signs of complications, such as hypotension or arrhythmias, following nitroglycerin administration.

✘Incorrect answer options:

Escort the client back to bed. While it might seem appropriate to return the client to bed, this action could further increase the heart's oxygen demand due to continued exertion. It is safer and more effective to stop activity immediately and help the client sit down where they are.

Perform an ECG. Performing an ECG is an important diagnostic step to assess for ischemia or arrhythmias, but it is not the first priority. The nurse should ensure the client is in a safe position and their immediate oxygen demand is reduced before performing further assessments.

Administer sublingual nitroglycerin. Nitroglycerin is an appropriate treatment for angina, but it should not be the first action. The client must be seated to reduce oxygen demand and to prevent the risk of falling if nitroglycerin causes dizziness or hypotension. Assessment of vital signs before administering nitroglycerin is also essential.

EXPLANATION

✔Correct answer:

Pulmonary edema. The clinical presentation of acute shortness of breath, pink frothy sputum, crackles, wheezes, hypotension, tachycardia, and tachypnea is classic for pulmonary edema, specifically acute cardiogenic pulmonary edema. This condition is often caused by left-sided heart failure, where the left ventricle fails to pump blood effectively, leading to increased pressure in the pulmonary veins and capillaries. As a result, fluid leaks into the alveoli, impairing gas exchange and causing severe respiratory distress.

Pulmonary edema frequently occurs in clients with underlying conditions such as heart failure, hypertension, and diabetes mellitus, all of which contribute to cardiovascular disease and poor ventricular function. The hallmark symptom of pink frothy sputum is caused by fluid mixed with air in the lungs, a critical diagnostic clue.

When the left ventricle cannot effectively pump blood, it backs up into the left atrium, pulmonary veins, and capillaries. This increases pulmonary capillary hydrostatic pressure, causing fluid to leak from the capillaries into the alveoli. This fluid disrupts gas exchange, resulting in hypoxemia and respiratory distress.

Imagine a sink (lungs) with a clogged drain (left-sided heart failure). As water (blood) backs up, it overflows, spilling into the surrounding area (alveoli), impairing normal function.

Pulmonary edema is a medical emergency requiring rapid interventions to restore oxygenation, reduce pulmonary congestion, and stabilize the client.

• Position the client in high Fowler’s position to improve lung expansion and reduce pulmonary venous return.
• Administer oxygen therapy or non-invasive positive-pressure ventilation (e.g., CPAP or BiPAP) to improve oxygenation and reduce the work of breathing.
• Administer prescribed medications:
  • Diuretics (e.g., furosemide) to reduce fluid volume and alleviate pulmonary congestion.
  • Vasodilators (e.g., nitroglycerin) to reduce preload and afterload, decreasing the workload on the heart.
  • Inotropic agents (e.g., dobutamine) if indicated, to improve left ventricular contractility in severe cases.
• Monitor for worsening signs of hypoxemia, arrhythmias, or respiratory failure, and prepare for possible intubation and mechanical ventilation if required.
• Address underlying causes (e.g., optimize heart failure management) to prevent recurrence.

✘Incorrect answer options:

Pneumothorax. Pneumothorax refers to the presence of air in the pleural space, causing lung collapse. Symptoms include sudden-onset chest pain, dyspnea, diminished or absent breath sounds on the affected side, and tracheal deviation in tension pneumothorax. Pink frothy sputum, crackles, and wheezes are not associated with pneumothorax.

Cardiac tamponade. Cardiac tamponade is caused by fluid accumulation in the pericardial sac, compressing the heart and impairing cardiac output. Symptoms include hypotension, jugular vein distension, and muffled heart sounds (Beck’s triad). Pulmonary symptoms such as pink frothy sputum and crackles are not characteristic of tamponade.

Pulmonary embolism. Pulmonary embolism presents with sudden-onset dyspnea, pleuritic chest pain, tachycardia, and hypoxemia. While tachycardia and respiratory distress are common, pink frothy sputum, crackles, and wheezes are not typical findings. Pulmonary embolism results from a blood clot in the pulmonary arteries, not fluid overload in the lungs.

EXPLANATION

✔Correct answer:

Left ventricular atrophy. As people age, left ventricular hypertrophy and stiffening of the myocardium and vascular walls are common physiological changes. However, atrophy of the left ventricular muscle is more likely in sedentary older adults, contributing to reduced cardiac reserve and a decreased ability to handle stress, particularly physical or emotional stress.

The left ventricle is responsible for pumping oxygenated blood to the rest of the body. With age, the myocardial cells degenerate, and the ventricular walls may lose elasticity and strength. This leads to:

• Reduced cardiac output: The heart's ability to increase output during stress is diminished.
• Impaired response to catecholamines: Older adults may not respond as robustly to adrenaline and other stress-related hormones, further limiting their capacity to cope with stress.
• Increased afterload: Stiffened arteries increase vascular resistance, requiring more effort for the heart to pump blood.

These changes are exacerbated in sedentary individuals, as lack of exercise accelerates cardiovascular deconditioning and worsens age-related cardiac changes.

Think of the heart as a rubber band. In a healthy adult, the rubber band stretches easily to handle extra work. In an older, sedentary person, the rubber band becomes stiff and brittle, losing its ability to stretch and contract efficiently under stress.

When caring for older adults with diminished cardiovascular stress responses, nurses should prioritize strategies to enhance cardiac function and minimize stress on the heart.

• Encourage regular exercise: Physical activity helps maintain cardiac reserve, improve ventricular function, and prevent further cardiovascular deconditioning.
• Monitor for signs of cardiac strain: Assess for fatigue, dyspnea, chest discomfort, or irregular heart rhythms during physical or emotional stress.
• Educate about stress management: Teach clients relaxation techniques, such as deep breathing or mindfulness, to mitigate the effects of emotional stress on the cardiovascular system.
• Control modifiable risk factors: Support clients in managing hypertension, diabetes, and lipid levels, which can exacerbate age-related cardiac changes.
• Promote a heart-healthy diet: Recommend a diet rich in fruits, vegetables, lean proteins, and low in sodium to maintain optimal cardiovascular health.

✘Incorrect answer options:

Irregular heartbeats: While arrhythmias, such as atrial fibrillation, are common in older adults, they do not specifically explain the reduced cardiovascular response to stress in sedentary individuals. Arrhythmias may complicate cardiac function but are not the primary issue in this scenario.

Peripheral vascular occlusion: Peripheral vascular disease (PVD) refers to the narrowing or blockage of peripheral blood vessels, usually caused by atherosclerosis. While PVD may cause leg pain or impaired circulation, it is not the primary reason older adults have a reduced cardiac response to stress.

Pacemaker placement: Pacemakers are used to correct bradycardia or other rhythm disturbances. However, not all older adults have pacemakers, and the need for a pacemaker is unrelated to the diminished cardiovascular response seen in sedentary older adults.

EXPLANATION

✔Correct answer:

Obtaining an infusion pump for the medication. Continuous intravenous nitroglycerin infusion is a potent vasodilator used to manage myocardial infarction (MI) by reducing myocardial oxygen demand and improving coronary blood flow. Because of its potency and narrow therapeutic window, it is essential to administer nitroglycerin using an infusion pump to maintain precise control of the dosage and avoid potentially dangerous complications, such as severe hypotension or inadequate therapeutic response. Infusion pumps ensure the medication is delivered at the exact rate prescribed, minimizing the risk of errors.

Key Pharmacologic Actions of Nitroglycerin:  

1. Dilates coronary arteries: Improves oxygen delivery to ischemic myocardial tissue.
2. Reduces preload and afterload: Decreases venous return and systemic vascular resistance, reducing myocardial oxygen demand.
3. Rapid onset and short duration: Nitroglycerin infusion requires precise titration, as its effects can occur quickly and subside once the infusion stops.

Without an infusion pump, fluctuations in the rate of administration could result in significant hemodynamic instability.

Administering nitroglycerin without a pump is like trying to pour a precise amount of water into a small glass from a large pitcher—it’s challenging to control. Using a pump is like using a spout with precise control to avoid overflow or underfill.

When administering intravenous nitroglycerin, nurses should prioritize safety and regular monitoring to prevent complications.

• Ensure an infusion pump is used: Verify that the pump is correctly calibrated and programmed to deliver the exact prescribed dose.
• Monitor blood pressure and heart rate frequently: Hypotension is a common side effect. Initial monitoring may be as frequent as every 5–15 minutes, especially during dose titration.
• Titrate dosage based on response: Follow the provider’s orders to adjust the infusion rate based on blood pressure, pain relief, or other clinical markers.
• Assess for side effects: Monitor for symptoms of hypotension (e.g., dizziness, lightheadedness), headache (a common side effect of nitroglycerin), or reflex tachycardia.
• Evaluate for therapeutic response: Observe for a decrease in chest pain, improved ECG changes, or stabilized hemodynamic parameters.
• Maintain IV patency: Ensure the IV line is patent, as extravasation of nitroglycerin can cause tissue irritation.

✘Incorrect answer options:

Monitoring BP every 4 hours: While monitoring blood pressure is critical during nitroglycerin infusion, every 4 hours is insufficient. Blood pressure should be checked frequently (e.g., every 5–15 minutes initially) to detect and respond to potential hypotension. This choice does not reflect the level of vigilance required for nitroglycerin infusion.

Monitoring urine output hourly: Although monitoring urine output is important in clients with myocardial infarction to assess renal perfusion and overall hemodynamic status, it is not directly related to the safe administration of nitroglycerin. This action is not as essential as ensuring accurate infusion via a pump.

Obtaining serum potassium levels daily: Nitroglycerin does not directly affect potassium levels. Monitoring potassium is more relevant for clients on medications like diuretics (e.g., furosemide) or conditions that predispose to electrolyte imbalances. This action is unrelated to the safe administration of nitroglycerin.

EXPLANATION

✔Correct answer:

The presence of crackles. The presence of crackles (also known as rales) during lung auscultation is a hallmark symptom of left-sided heart failure. This condition occurs when the left ventricle cannot effectively pump blood forward into systemic circulation, leading to a backup of blood into the pulmonary circulation. The resulting increased hydrostatic pressure in the pulmonary capillaries causes fluid to leak into the alveoli, producing crackling sounds during inspiration. Other symptoms of left-sided heart failure include dyspnea, orthopnea (difficulty breathing when lying flat), fatigue, and in severe cases, pink-tinged frothy sputum, indicating pulmonary edema.

Left-sided heart failure leads to a reduction in cardiac output and an increase in pulmonary venous pressure. The buildup of fluid in the lungs (pulmonary congestion) impairs gas exchange, which explains the shortness of breath and fatigue experienced by patients. Crackles are caused by the sudden opening of small airways and alveoli that are collapsed or filled with fluid.

Imagine the left side of the heart as a sump pump that moves water out of a basement. If the pump fails to work efficiently, water backs up and floods the basement (lungs), and you can hear the sound of water bubbling or sloshing (crackles) as it moves through the flooded area.

Nurses play a critical role in managing left-sided heart failure by focusing on optimizing oxygenation, reducing fluid overload, and supporting cardiac function.

• Assess lung sounds regularly for the presence of crackles or worsening pulmonary congestion.
• Monitor the patient's oxygen saturation and provide supplemental oxygen as needed to improve gas exchange.
• Administer prescribed medications, such as diuretics (e.g., furosemide), to reduce fluid buildup, and ACE inhibitors or beta-blockers to improve cardiac output.
• Encourage the patient to rest in a semi-Fowler’s or high-Fowler’s position to facilitate easier breathing and decrease venous return.
• Educate the patient on reducing sodium intake, adhering to fluid restrictions, and recognizing early signs of heart failure exacerbation.

✘Incorrect answer options:

Irregular heart rhythms (arrhythmias). While arrhythmias are common in patients with heart disease or heart failure, they are not specific to left-sided heart failure and do not directly cause pulmonary symptoms like crackles. Arrhythmias often occur as a secondary complication rather than a primary feature.

Liver engorgement. Liver engorgement, or hepatomegaly, is a symptom more commonly associated with right-sided heart failure due to systemic venous congestion. It is not a characteristic finding of left-sided heart failure, which primarily affects the pulmonary circulation.

Low blood pressure (hypotension). Hypotension may occur in severe heart failure due to poor cardiac output, but it is not a defining or specific symptom of left-sided heart failure. It does not explain pulmonary congestion or the presence of crackles in the lungs.

EXPLANATION

✔Correct answer:

Extremely anxious. In clients with severe pulmonary edema, extreme anxiety is expected due to the profound respiratory distress and the accompanying sense of impending doom caused by air hunger and difficulty breathing. Pulmonary edema leads to the accumulation of fluid in the alveoli, impairing gas exchange and resulting in severe hypoxemia. Clients often experience acute dyspnea, tachypnea, and a feeling of suffocation, which can cause intense emotional distress and panic.

The fluid buildup in the alveoli reduces oxygen delivery to the bloodstream, triggering a cascade of symptoms, including shortness of breath, tachycardia, and pink, frothy sputum. The inability to adequately oxygenate leads to a sympathetic nervous system (SNS) response, which manifests as extreme anxiety or fear.

Imagine trying to breathe through a straw while submerged underwater. The inability to get enough air quickly leads to panic and fear, similar to what clients with pulmonary edema experience.

Extreme anxiety not only reflects the client’s emotional response to their condition but also exacerbates respiratory distress by increasing oxygen demand. The nurse’s immediate priority is to address both the physical and emotional needs of the client.

• Position the client in high Fowler’s position to maximize lung expansion and reduce pulmonary congestion.
• Administer supplemental oxygen or non-invasive ventilation (e.g., CPAP or BiPAP) to improve oxygenation and relieve air hunger.
• Provide reassurance to reduce emotional distress. Use calm and clear communication to explain the interventions and reassure the client that help is being provided.
• Administer prescribed diuretics (e.g., furosemide) to reduce fluid overload and alleviate pulmonary congestion.
• Monitor for worsening hypoxemia or signs of impending respiratory failure that may require intubation and mechanical ventilation.

✘Incorrect answer options:

Slightly anxious. Clients with severe pulmonary edema would not exhibit slight anxiety because the acute respiratory distress triggers intense emotional and physiological responses.

Mildly anxious. Mild anxiety may occur in less severe conditions where breathing is not severely compromised. Pulmonary edema typically causes extreme anxiety due to the sensation of suffocation and lack of oxygen.

Moderately anxious. Moderate anxiety might be seen in clients with stable but chronic respiratory conditions. However, severe pulmonary edema is an acute, life-threatening emergency that leads to extreme anxiety and panic.

EXPLANATION

✔Correct answer:

Heart transplantation. Heart transplantation is the definitive treatment for clients with end-stage cardiomyopathy who have not responded to medical or less invasive therapies. Cardiomyopathy that progresses to end-stage heart failure involves severe impairment of the heart's ability to pump blood effectively, leading to poor prognosis despite optimal medical management. A heart transplant replaces the diseased heart with a healthy donor heart, offering the best chance of improved survival and quality of life for eligible clients.

Heart transplantation is generally reserved for clients who meet strict eligibility criteria, including:

• End-stage heart failure with severe symptoms (NYHA Class III or IV) that persist despite maximum medical therapy.
• Absence of other significant comorbidities, such as uncontrolled infection, active cancer, or severe organ dysfunction.
• Psychosocial readiness and ability to adhere to lifelong immunosuppressive therapy.

Think of a car engine (the heart) that has failed completely after years of use. A transplant is like replacing the entire engine with a new one, offering the vehicle (the body) a chance to function again.

In end-stage cardiomyopathy, the myocardium becomes so damaged that it cannot maintain adequate cardiac output to support the body's metabolic needs, even with medications, mechanical support (e.g., intra-aortic balloon pump or ventricular assist devices), or other interventions. A heart transplant provides a functional heart to restore effective blood circulation.

Nurses play a vital role in the pre- and post-transplant care of clients undergoing heart transplantation.

• Pre-transplant care:
  • Ensure the client understands the transplant process, including risks, benefits, and lifelong medication adherence (e.g., immunosuppressive therapy).
  • Monitor for worsening symptoms of heart failure, such as dyspnea, fatigue, and fluid retention, while awaiting a donor heart.
  • Provide emotional support and counseling, as the waiting period can be stressful and anxiety-inducing.
• Post-transplant care:
  • Monitor for signs of organ rejection, such as fever, weight gain, fatigue, or changes in cardiac function.
  • Administer immunosuppressive medications (e.g., tacrolimus, mycophenolate mofetil) as prescribed to prevent rejection.
  • Educate the client about infection prevention, as immunosuppression increases susceptibility to infections.
  • Promote adherence to lifestyle modifications, such as maintaining a low-sodium diet and engaging in cardiac rehabilitation programs.

✘Incorrect answer options:

Cardiac catheterization. Cardiac catheterization is a diagnostic procedure used to assess coronary artery function and cardiac pressures. While it can guide treatment decisions, it does not provide definitive therapy for end-stage cardiomyopathy.

Coronary artery bypass graft (CABG). CABG is a surgical procedure used to bypass blocked coronary arteries and restore blood flow to the myocardium. It is primarily indicated for ischemic heart disease, not end-stage cardiomyopathy unrelated to coronary artery disease.

Intra-aortic balloon pump (IABP). An IABP is a temporary mechanical device used to improve cardiac output and reduce myocardial workload in acute heart failure or cardiogenic shock. While it can stabilize clients temporarily, it is not a definitive treatment for end-stage cardiomyopathy.

EXPLANATION

✔Correct answer:

Acute renal failure. The client is demonstrating signs of acute renal failure (ARF), also referred to as acute kidney injury (AKI). The primary indicators include low urine output (oliguria), elevated blood urea nitrogen (BUN), and serum creatinine levels, which suggest impaired kidney function. These findings are especially concerning 24 hours post-cardiac surgery, as reduced renal perfusion is a common complication due to factors such as hypoperfusion, hypotension, or nephrotoxic medications often used during or after surgery (e.g., anesthetics or contrast agents).

Acute renal failure occurs when the kidneys suddenly lose their ability to filter waste products from the blood. This can be caused by prerenal factors (e.g., reduced blood flow to the kidneys), intrarenal factors (e.g., damage to the kidney tissue itself), or postrenal factors (e.g., obstruction of urine outflow). In this scenario, prerenal causes, such as decreased renal perfusion secondary to hypotension or fluid volume shifts post-surgery, are the most likely contributors.

Think of the kidneys as a water filtration system in your home. If the water supply to the filter is drastically reduced (prerenal cause) or the filter becomes clogged with debris (intrarenal cause), the system cannot clean the water effectively, leading to waste buildup (elevated BUN and creatinine).

The nurse's role in managing a client at risk for acute renal failure includes assessing, monitoring, and preventing further renal damage.

• Monitor urine output closely; less than 30 mL/hour is indicative of oliguria and warrants immediate attention.
• Assess fluid status by monitoring daily weights, blood pressure, and signs of fluid overload or dehydration.
• Evaluate laboratory values regularly, including BUN, creatinine, and electrolyte levels, especially potassium.
• Administer prescribed IV fluids or diuretics as directed, while being cautious not to overload the client with fluids.
• Avoid nephrotoxic drugs when possible and advocate for dose adjustments if the client has compromised kidney function.
• Communicate findings to the healthcare provider to facilitate early interventions, such as renal replacement therapy if needed.

✘Incorrect answer options:

Hypovolemia: While hypovolemia can cause reduced urine output and prerenal azotemia (elevated BUN due to low blood flow to the kidneys), this client has already received a bolus of IV fluids. Persistent oliguria despite fluid resuscitation points to intrinsic kidney dysfunction rather than ongoing hypovolemia.

Urinary tract infection (UTI): UTIs can affect kidney function if they progress to pyelonephritis (infection of the kidneys). However, UTIs are typically associated with symptoms such as dysuria, fever, or flank pain, which are not described in this client. Elevated BUN and creatinine are not hallmark findings of uncomplicated UTIs.

Glomerulonephritis: Glomerulonephritis is an inflammatory condition of the kidney's glomeruli that often presents with hematuria, proteinuria, and hypertension. This client's clinical presentation (oliguria and elevated BUN/creatinine post-surgery) is more consistent with acute renal failure, likely of prerenal origin, rather than glomerulonephritis.

EXPLANATION

✔Correct answer:

Heart failure. The most commonly associated condition with cardiomyopathy is heart failure. Cardiomyopathy affects the structure and function of the heart muscle, impairing the heart's ability to pump blood effectively. Over time, this can lead to heart failure, a chronic condition where the heart cannot meet the body's demands for oxygenated blood. Symptoms of heart failure caused by cardiomyopathy include shortness of breath (dyspnea), fluid retention, peripheral edema, fatigue, and in severe cases, pulmonary congestion or ascites.

Cardiomyopathy, whether dilated, hypertrophic, or restrictive, compromises cardiac function in different ways:

• Dilated cardiomyopathy results in weakened, enlarged ventricles that cannot pump blood effectively, leading to systolic dysfunction.
• Hypertrophic cardiomyopathy causes thickened myocardium and impaired ventricular filling, leading to diastolic dysfunction.
• Restrictive cardiomyopathy involves stiff ventricles, limiting diastolic filling and reducing stroke volume.

In all cases, the reduced cardiac output triggers compensatory mechanisms, such as activation of the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system. These mechanisms initially help maintain blood flow but eventually contribute to fluid retention and worsening heart failure symptoms.

Think of the heart as a pump and the body's tissues as a garden. If the pump is weak or inefficient (cardiomyopathy), the garden (tissues) doesn't get enough water (oxygenated blood), leading to dryness (fatigue) and water pooling elsewhere (fluid retention and edema).

Managing heart failure in clients with cardiomyopathy involves improving cardiac function, relieving symptoms, and preventing complications.

• Monitor for signs of fluid overload, such as weight gain, peripheral edema, and pulmonary congestion.
• Administer prescribed medications, such as:
  • Diuretics to reduce fluid retention and edema.
  • ACE inhibitors or ARBs to reduce afterload and improve cardiac output.
  • Beta-blockers to control heart rate and reduce myocardial workload.
  • Aldosterone antagonists (e.g., spironolactone) to decrease fluid retention.
• Encourage the client to adhere to a low-sodium diet and fluid restrictions to minimize fluid retention.
• Monitor daily weights to detect early signs of fluid overload.
• Provide education on recognizing worsening symptoms of heart failure, such as increased dyspnea, orthopnea, or fatigue, and encourage prompt medical follow-up.

✘Incorrect answer options:

Diabetes. While diabetes is a risk factor for cardiovascular diseases, it is not directly caused by cardiomyopathy. However, diabetes can exacerbate heart failure if left uncontrolled, due to its effects on blood vessels and myocardial tissue.

Myocardial infarction (MI). Myocardial infarction can lead to ischemic cardiomyopathy, a specific subtype of dilated cardiomyopathy caused by extensive damage to the myocardium. However, it is not a recurring condition associated with all types of cardiomyopathy and is more of a cause rather than a consequence.

Pericardial effusion. Pericardial effusion, the accumulation of fluid in the pericardial sac, is typically caused by pericarditis, trauma, or cancer. It is not commonly associated with cardiomyopathy, as cardiomyopathy primarily involves the myocardium (heart muscle) rather than the pericardium.

EXPLANATION

✔Correct answer:

Stable angina. Stable angina is characterized by predictable chest pain or discomfort that occurs during physical exertion, stress, or emotional strain. The pain is caused by myocardial ischemia, which occurs when the oxygen supply to the heart muscle is insufficient to meet the increased demand. Stable angina typically resolves with rest or after taking nitroglycerin, which helps to dilate coronary arteries and reduce myocardial oxygen demand.

Stable angina results from coronary artery disease (CAD), in which atherosclerotic plaques narrow the coronary arteries. During periods of increased myocardial oxygen demand (e.g., exercise or stress), the restricted blood flow cannot meet the oxygen needs of the myocardium, leading to ischemia and chest pain. The pain is predictable and follows a consistent pattern, which distinguishes it from other forms of angina.

Think of the heart as a car engine. Stable angina is like the car running low on fuel (oxygen supply) when you press the gas pedal (increased activity). Reducing speed (rest) or adding fuel (medication) resolves the problem.

Nurses play an essential role in managing stable angina by educating clients on symptom management, preventing progression to unstable angina, and optimizing lifestyle and medication adherence.

• Assess the characteristics of chest pain, including location, intensity, duration, and triggers (e.g., exercise, stress).
• Administer prescribed medications, such as:
  • Nitroglycerin (sublingual or spray) to relieve acute chest pain.
  • Beta-blockers to reduce myocardial oxygen demand by lowering heart rate and contractility.
  • Calcium channel blockers to improve coronary blood flow and reduce myocardial workload.
  • Aspirin or other antiplatelet agents to prevent thrombus formation.
• Educate the client on avoiding triggers, such as overexertion or emotional stress, and the importance of rest when symptoms occur.
• Encourage lifestyle modifications, including smoking cessation, a heart-healthy diet, regular exercise, and weight management, to reduce cardiovascular risk factors.
• Monitor for signs of progression to unstable angina or other complications, such as increasing frequency or severity of chest pain, which requires immediate medical attention.

✘Incorrect answer options:

Anxiety. Anxiety can cause chest discomfort, typically due to hyperventilation or tension, but it is not related to myocardial ischemia. Anxiety-related chest pain does not follow a predictable pattern of exertion and relief with rest or nitroglycerin.

Unstable angina. Unstable angina is a more severe form of angina that occurs unpredictably, often at rest, and does not resolve with rest or nitroglycerin. It indicates worsening ischemia and is considered a medical emergency that may precede a myocardial infarction.

Variant angina. Variant angina (Prinzmetal’s angina) is caused by coronary artery spasm rather than atherosclerosis. It typically occurs at rest, often at night or early morning, and is not necessarily triggered by exertion or stress. Nitroglycerin can relieve the pain, but the condition has an unpredictable pattern.

EXPLANATION

✔Correct answer:

5 to 10 minutes. When administered intravenously (IV), furosemide, a loop diuretic, has an onset of action within 5 to 10 minutes. The rapid onset makes it an effective medication for the immediate relief of fluid overload symptoms in clients with heart failure, such as pulmonary edema, dyspnea, and elevated blood pressure. Furosemide works by inhibiting sodium, potassium, and chloride reabsorption in the loop of Henle in the kidneys, which promotes significant diuresis and reduces fluid volume.

The IV route ensures that furosemide bypasses gastrointestinal absorption, allowing it to reach the bloodstream almost immediately. This is particularly advantageous in acute situations where prompt reduction of fluid overload is necessary, as in cases of pulmonary edema or severe heart failure exacerbations.

Think of furosemide as a "drain opener" for the body's fluid retention. When given through an IV, it starts working very quickly, like pouring a fast-acting liquid drain cleaner directly into a clogged pipe to rapidly clear it.

Nurses must monitor the client closely for the desired effects of diuresis as well as potential side effects associated with furosemide administration.

• Monitor urine output to assess the effectiveness of the drug. Diuresis typically begins within minutes after IV administration.
• Assess vital signs, particularly blood pressure, as furosemide can cause hypotension due to fluid loss.
• Monitor serum electrolytes, particularly potassium and magnesium, as furosemide can cause significant losses of these electrolytes, leading to hypokalemia or hypomagnesemia.
• Observe for signs of dehydration, such as dry mucous membranes, hypotension, and tachycardia.
• Educate the client about potential side effects, such as dizziness or lightheadedness, and instruct them to call for assistance before ambulating.

✘Incorrect answer options:

30 to 60 minutes. This time frame is the typical onset of action for oral furosemide, not the IV form. When administered orally, furosemide must be absorbed through the gastrointestinal tract, leading to a slower onset of action compared to the IV route.

2 to 4 hours. This is the peak diuretic effect of oral furosemide but not its onset of action. IV furosemide works much faster than this, with diuresis beginning within minutes of administration.

6 to 8 hours. This is the duration of action of furosemide (both oral and IV), not its onset. While the drug’s effects may persist for this long, the goal in acute fluid overload situations is to achieve rapid relief, which occurs well before this time frame with IV administration.

EXPLANATION

✔Correct answer:

The 76-year-old client admitted 1 hour ago with new-onset atrial fibrillation receiving IV diltiazem (Cardizem). New-onset atrial fibrillation (AFib) is a condition requiring immediate assessment and monitoring, particularly because it is associated with potential complications such as hemodynamic instability, rapid ventricular response (RVR), and an increased risk of thromboembolic events (e.g., stroke). The client receiving IV diltiazem (a calcium channel blocker) requires close observation for changes in heart rate, rhythm, and blood pressure, as this medication can cause hypotension or bradycardia. Additionally, as this client was admitted just 1 hour ago, there may still be ongoing acute changes requiring prompt nursing intervention.

Atrial fibrillation with rapid heart rhythms is like an engine overheating—it needs immediate attention to avoid long-term damage or breakdown (complications like stroke or heart failure).

Nurse Emily should prioritize this client due to the acute nature of the condition and the potential for rapid deterioration.

• Monitor the heart rate and rhythm continuously for signs of rapid ventricular response (RVR) or other dysrhythmias.
• Assess the client’s blood pressure frequently, as IV diltiazem may cause hypotension.
• Assess for signs of decreased perfusion or oxygenation, such as dizziness, chest pain, dyspnea, or syncope.
• Evaluate the client for potential stroke symptoms (e.g., facial droop, slurred speech, unilateral weakness) because atrial fibrillation significantly increases the risk of thromboembolism.
• Ensure the IV line is patent and medication administration is being titrated properly based on prescribed parameters (e.g., target heart rate).

✘Incorrect answer options:

The 58-year-old client admitted 2 days ago with heart failure, stable BP, and a respiratory rate of 21. This client is relatively stable, with normal blood pressure and a respiratory rate within acceptable limits. While heart failure requires ongoing monitoring, there are no signs of acute decompensation or immediate instability, making this client a lower priority than the one with new-onset AFib.

The 88-year-old client with end-stage right-sided heart failure, hypotension, and a DNR order. While this client has hypotension and a DNR order, the end-stage nature of their condition indicates that the focus of care may be on comfort measures rather than aggressive interventions. Unless there is a specific acute concern requiring intervention (e.g., symptomatic hypotension or worsening dyspnea), this client is not the highest priority.

The 62-year-old client admitted with thrombophlebitis and receiving IV heparin. Thrombophlebitis is a serious condition requiring anticoagulation therapy, but this client is receiving IV heparin, which is appropriate treatment. Unless there are signs of complications (e.g., pulmonary embolism, excessive bleeding, or significant pain), this client is not the most urgent priority.

EXPLANATION

✔Correct answer:

Anorexia, nausea, and visual disturbances.  The classic signs of digoxin toxicity include gastrointestinal symptoms (e.g., anorexia, nausea, vomiting), visual disturbances (e.g., blurred vision, yellow-green halos), and cardiac dysrhythmias. These symptoms occur due to the narrow therapeutic window of digoxin and its effects on the sodium-potassium ATPase pump, which affects myocardial function and other excitable tissues like the gastrointestinal tract and visual pathways.

Pathophysiology of Digoxin Toxicity:  

• Digoxin increases intracellular calcium by inhibiting the sodium-potassium ATPase pump, which enhances cardiac contractility (positive inotropy). However, excessive digoxin levels disrupt electrolyte balance, leading to toxic effects, particularly in excitable tissues.
• GI symptoms: The first signs of toxicity are often anorexia, nausea, and vomiting, likely due to digoxin’s effects on the chemoreceptor trigger zone in the central nervous system.
• Visual disturbances: Visual changes, such as blurred vision or seeing halos around lights, occur due to digoxin's impact on retinal cones and photoreceptor pathways.
• Cardiac dysrhythmias: Digoxin toxicity can cause life-threatening arrhythmias, such as premature ventricular contractions, bradycardia, or atrioventricular block.

Imagine digoxin as a “fuel enhancer” for the heart. While it boosts performance, using too much can cause the engine (heart) to overheat and misfire (toxicity), leading to strange signals like blurry lights (visual changes) and queasiness (GI upset).

Nurses play a crucial role in preventing, identifying, and managing digoxin toxicity in clients.

• Monitor digoxin levels: Ensure serum levels remain within the therapeutic range (0.8–2.0 ng/mL). Levels >2.0 ng/mL are considered toxic.
• Assess for early signs of toxicity: Watch for anorexia, nausea, vomiting, and visual changes, as these often precede severe complications like dysrhythmias.
• Check potassium levels: Hypokalemia increases the risk of digoxin toxicity because low potassium enhances digoxin’s effects on the myocardium. Ensure potassium levels are within normal limits (3.5–5.0 mEq/L).
• Monitor cardiac rhythm: Look for bradycardia, AV block, or ventricular dysrhythmias on ECG, as these can indicate toxicity.
• Educate the client: Teach clients to recognize early symptoms of toxicity and report them promptly. Also, stress the importance of not skipping or doubling doses.
• Administer antidote if needed: For severe digoxin toxicity, digoxin immune Fab (Digibind) may be administered to bind and neutralize excess digoxin.

✘Incorrect answer options:

Thrombocytopenia and weight gain: Digoxin toxicity does not typically cause thrombocytopenia or weight gain. Weight gain is more commonly associated with fluid retention in heart failure, but it is not a direct symptom of toxicity.

Diarrhea and hypotension: While diarrhea can occasionally occur with digoxin use, it is not a hallmark symptom of toxicity. Hypotension is not a common feature of digoxin toxicity; bradycardia and arrhythmias are more significant cardiac findings.

Fatigue and muscle twitching: Although fatigue may occur with digoxin use, it is nonspecific and not a reliable indicator of toxicity. Muscle twitching is more associated with electrolyte imbalances like hypocalcemia or hypomagnesemia, rather than digoxin toxicity.