Question A nurse is caring for a patient with congestive heart failure (CHF) who presents with shortness of breath, orthopnea, and edema of the lower extremities. Which of the following actions should the nurse take first?

A. Administer intravenous diuretics
B. Prepare the patient for immediate surgery
C. Position the patient in a high Fowler’s position
D. Apply oxygen therapy at 2 L/min via nasal cannula
E. Start an intravenous line with normal saline

Correct Answer: C. Position the patient in a high Fowler’s position

Rationale: Positioning the patient in a high Fowler’s position is the first and most immediate action that can help alleviate shortness of breath by reducing venous return to the heart and decreasing pulmonary congestion. This position can also help improve oxygenation and make breathing easier for the patient. Administering diuretics and applying oxygen therapy are also important interventions for a patient with CHF, but ensuring the patient is in a position that maximally reduces respiratory distress is a priority. Starting an intravenous line with normal saline and preparing the patient for surgery are not immediate priorities given the symptoms presented.

Question A nurse is educating a patient with congestive heart failure about dietary modifications. Which of the following dietary instructions is most appropriate for the nurse to emphasize?

A. Increase protein intake to promote muscle strength
B. Restrict sodium intake to less than 2,000 mg per day
C. Consume a high-carbohydrate diet for more energy
D. Increase fluid intake to prevent dehydration
E. Eliminate potassium from the diet to avoid hyperkalemia

Correct Answer: B. Restrict sodium intake to less than 2,000 mg per day

Rationale: In congestive heart failure, sodium restriction is crucial because sodium can cause fluid retention, worsening the heart’s workload and exacerbating symptoms like edema and shortness of breath. Limiting sodium intake helps to control blood pressure and decrease the heart’s workload, thus managing CHF symptoms more effectively. Dietary modifications focusing on sodium restriction can significantly impact the management and progression of CHF. While other dietary components like protein, carbohydrates, and potassium are important, they do not have the same immediate impact on fluid retention as sodium does.

Question A nurse is assessing a patient with congestive heart failure. Which of the following findings would be considered a late sign of CHF?

A. Weight gain
B. Crackles on auscultation
C. Pitting edema in the lower extremities
D. Elevated jugular venous pressure
E. Paroxysmal nocturnal dyspnea

Correct Answer: E. Paroxysmal nocturnal dyspnea

Rationale: Paroxysmal nocturnal dyspnea is a late sign of congestive heart failure and indicates severe disease. It is characterized by sudden, severe shortness of breath at night that awakens the patient from sleep, requiring them to sit up or stand to relieve the symptoms. This symptom occurs due to fluid accumulation in the lungs when lying down, reflecting advanced heart failure where the heart’s pumping capacity is significantly compromised. Weight gain, crackles on auscultation, pitting edema, and elevated jugular venous pressure are earlier signs of CHF that indicate fluid overload and increased cardiac pressure, but they do not specifically indicate the severity as paroxysmal nocturnal dyspnea does.

Question A patient with congestive heart failure is prescribed enalapril. The nurse knows that the primary reason for prescribing this medication is to:

A. Increase heart rate
B. Dilate the veins and decrease venous return
C. Increase the force of cardiac contractions
D. Reduce blood pressure and afterload
E. Directly remove excess body fluid

Correct Answer: D. Reduce blood pressure and afterload

Rationale: Enalapril is an ACE inhibitor that is commonly used in the management of congestive heart failure. The primary action of this medication is to block the conversion of angiotensin I to angiotensin II, leading to vasodilation, which in turn reduces blood pressure and the heart’s afterload. By decreasing afterload, enalapril helps to improve cardiac output and reduce the workload on the heart, which is crucial in managing CHF. It does not directly increase heart rate, increase the force of cardiac contractions, directly remove excess fluid, or primarily act on venous dilation, but rather focuses on improving heart efficiency by reducing systemic resistance.

Question A nurse is planning care for a patient with congestive heart failure who has been experiencing fatigue. Which of the following interventions should be included in the plan of care?

A. Encourage complete bed rest throughout the day
B. Schedule physical activities followed by periods of rest
C. Limit fluid intake to decrease the workload on the heart
D. Provide high-calorie meals three times a day
E. Insist on participation in group physical therapy sessions daily

Correct Answer: B. Schedule physical activities followed by periods of rest

Rationale: For patients with congestive heart failure experiencing fatigue, it is important to balance activity with rest. Scheduling physical activities followed by periods of rest helps to preserve energy and prevent excessive fatigue, while still promoting physical conditioning and preventing the negative effects of immobility. Complete bed rest is not advised as it can lead to deconditioning and worsen CHF symptoms. Limiting fluid intake and providing high-calorie meals are part of managing fluid and nutritional status but do not address activity-rest balance. Group physical therapy may be beneficial, but it must be tailored to the individual’s tolerance and should not be insisted upon daily without considering the patient’s overall condition and energy levels.

Question During a home visit, a nurse notices that a patient with congestive heart failure (CHF) has gained 3 pounds in the last 2 days. What is the nurse’s best initial action?

A. Advise the patient to stop taking their current medications
B. Instruct the patient to limit fluid intake immediately
C. Contact the healthcare provider to report the weight gain
D. Recommend starting a weight loss diet
E. Suggest increasing diuretic dosage without consulting a doctor

Correct Answer: C. Contact the healthcare provider to report the weight gain

Rationale: A rapid weight gain of 3 pounds or more in a few days can indicate worsening fluid retention in a patient with congestive heart failure, signaling a potential exacerbation of CHF. The best initial action is for the nurse to contact the healthcare provider to report this change. This allows for timely assessment and adjustment of the patient’s treatment plan, potentially including modifications to medication regimens. Advising the patient to stop taking their current medications, limiting fluid intake without professional guidance, recommending a weight loss diet, or suggesting changes in medication dosage without consulting a healthcare provider could be harmful and are not appropriate initial steps.

Question A nurse is educating a patient with congestive heart failure on recognizing symptoms of fluid overload. Which symptom should the nurse emphasize as an early sign to report?

A. Increased appetite
B. Decreased urination
C. Sudden dizziness
D. Dry, itchy skin
E. Difficulty breathing while lying flat

Correct Answer: E. Difficulty breathing while lying flat

Rationale: Difficulty breathing while lying flat, known as orthopnea, is an important early symptom of fluid overload in patients with congestive heart failure that should be promptly reported. This symptom occurs because when the patient lies down, fluid redistributes from the lower body to the lungs, increasing pulmonary pressure and causing difficulty breathing. Reporting this symptom early can allow for timely interventions to manage fluid overload and prevent further exacerbation of CHF. Increased appetite, decreased urination, sudden dizziness, and dry, itchy skin may also be relevant in the broader context of health, but they are not as directly indicative of fluid overload in CHF as orthopnea.

Question Which of the following is a priority nursing intervention for a patient with congestive heart failure and pulmonary edema?

A. Monitoring daily caloric intake
B. Administering prescribed diuretics
C. Implementing a strict no-salt diet
D. Providing skin care to prevent breakdown
E. Encouraging frequent ambulation

Correct Answer: B. Administering prescribed diuretics

Rationale: For a patient with congestive heart failure and pulmonary edema, administering prescribed diuretics is a priority nursing intervention. Diuretics help to reduce fluid volume, decreasing pulmonary congestion and edema, which directly addresses the immediate life-threatening aspect of pulmonary edema. While monitoring caloric intake, implementing a no-salt diet, providing skin care, and encouraging ambulation are important aspects of comprehensive care for a patient with CHF, they do not address the acute issue of pulmonary edema as directly and urgently as administering diuretics.

Question A patient with congestive heart failure is being discharged from the hospital. What instruction should the nurse emphasize to prevent readmission?

A. Avoid all forms of exercise
B. Weigh yourself daily at the same time
C. Only check blood pressure weekly
D. Increase salt intake to improve taste of food
E. Take diuretics in the morning only if feeling short of breath

Correct Answer: B. Weigh yourself daily at the same time

Rationale: Educating the patient to weigh themselves daily at the same time is crucial in managing congestive heart failure and preventing readmission. This practice helps to monitor for rapid weight changes, indicating fluid retention or loss, and allows for early intervention before symptoms worsen. Consistent daily monitoring provides a more accurate assessment of the patient’s fluid status than sporadic checks. Avoiding all forms of exercise, only checking blood pressure weekly, increasing salt intake, and taking diuretics only when symptomatic are not advisable practices and do not support the goal of preventing readmission for CHF.

Question For a patient with advanced congestive heart failure, which of the following symptoms would indicate the need for immediate evaluation by a healthcare provider?

A. Mild nausea after eating
B. Slight swelling of the ankles
C. Increase in appetite
D. Sudden weight gain of 4 pounds in 2 days
E. Occasional cough with clear sputum

Correct Answer: D. Sudden weight gain of 4 pounds in 2 days

Rationale: A sudden weight gain of 4 pounds in 2 days in a patient with advanced congestive heart failure is a critical indicator of acute fluid retention and warrants immediate evaluation by a healthcare provider. This significant weight gain suggests a rapid worsening of the patient’s condition, potentially indicating an acute exacerbation of heart failure that requires prompt medical intervention to prevent further complications. Mild nausea, slight swelling of the ankles, an increase in appetite, and an occasional cough with clear sputum, while important to monitor, do not signal an immediate crisis as clearly and urgently as a rapid and significant weight gain.

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