Heart Failure

Every question here, with the answer

1. At 0630, a patient admitted with HF tells you, “I couldn’t breathe lying flat, so I slept upright in the recliner and used three pillows.” Which nursing documentation best captures this finding?

   1. Reports fatigue with activities of daily living; no respiratory concern documented.
   2. Reports difficulty breathing when lying flat; slept upright in recliner with three pillows; finding consistent with orthopnea.
   3. Reports edema from fluid retention; socks and shoes fit poorly.
   4. Reports chest pain with activity relieved by rest; assess using PQRST.

   Answer: Reports difficulty breathing when lying flat; slept upright in recliner with three pillows; finding consistent with orthopnea.

   The correct note documents the patient’s breathing difficulty when lying flat and the need to sleep upright/on pillows, which matches orthopnea. The other options describe possible HF-related findings, but they do not capture what the patient actually reported in this situation.

2. At 0600 you need a daily weight for a patient with HF who has been receiving diuretic therapy. Which measurement steps are consistent with the section? Select all that apply.

   1. Document today’s weight without noting that the patient wore heavy shoes instead of usual garments.
   2. Use the same garments as prior weights when possible, or weigh nude if appropriate.
   3. Obtain the weight after the patient has been drinking morning fluids to reflect the day’s intake.
   4. Ask the patient to void before obtaining the morning weight.
   5. Delay the weight until later in the day if the patient already voided before you entered.

   Answer: Use the same garments as prior weights when possible, or weigh nude if appropriate., Ask the patient to void before obtaining the morning weight.

   The section recommends a morning weight after voiding and with consistent clothing, or nude if possible, to make weight comparisons meaningful. The other options introduce avoidable variation in timing, fluid intake, or clothing, which makes the documented weight less reliable.

3. At 2100, a patient with HF is sitting low in bed, reports shortness of breath, and the oxygen saturation is 90%. There is an order for supplemental oxygen. What should you document as the priority nursing action?

   1. Completed abdominal assessment for ascites before addressing dyspnea.
   2. Started the daily weight early to evaluate response to diuretic therapy.
   3. Encouraged activity to test whether dyspnea worsens with exertion.
   4. Raised patient to high Fowlers and applied ordered supplemental oxygen for dyspnea.

   Answer: Raised patient to high Fowlers and applied ordered supplemental oxygen for dyspnea.

   The correct action addresses dyspnea directly by positioning the patient in high Fowlers and using ordered oxygen. Daily weight and abdominal assessment may be relevant to HF care, but they do not take priority over the patient’s current oxygenation problem; encouraging activity is not supported here.

4. During an evening chart review, you see BNP results of 500 pg/mL at 0800, 750 pg/mL at 1700, and 1500 pg/mL at 2300 for a patient admitted with acute left-sided HF. Which note best interprets this trend based on the section?

   1. Rising BNP confirms coronary artery blockage and should be charted as the cause of HF.
   2. Rising BNP primarily documents hepatic congestion from right-sided heart failure.
   3. Rising BNP may reflect increased myocardial stretch as atrial and ventricular pressure gradients rise; correlate with clinical presentation.
   4. Rising BNP is expected only from age and does not require comparison with symptoms.

   Answer: Rising BNP may reflect increased myocardial stretch as atrial and ventricular pressure gradients rise; correlate with clinical presentation.

   The section links rising BNP with increased myocardial stretch and rising pressure gradients, and it also emphasizes assessing levels with clinical presentation. BNP alone is not documented as confirming coronary blockage, age is not the only explanation, and hepatic congestion is tied to liver function tests rather than BNP in this section.

5. At the start of shift, a patient with HF has a wet cough and crackles at the bases. Which details should you include in the respiratory assessment note according to the section? Select all that apply.

   1. Where the adventitious breath sounds are heard.
   2. Only the oxygen saturation, because breath-sound location is not part of the assessment.
   3. Any adventitious lung sounds heard.
   4. A statement that lung findings are unrelated to HF unless chest pain is present.
   5. Whether a cough is present and sputum color, consistency, and amount.

   Answer: Where the adventitious breath sounds are heard., Any adventitious lung sounds heard., Whether a cough is present and sputum color, consistency, and amount.

   The correct choices reflect the section’s respiratory assessment details: abnormal sounds, cough and sputum characteristics, and location of sounds. The other options minimize or misstate the assessment; the section specifically includes lung findings as part of HF assessment.

6. At 0900, before administering an ordered HF medication, you document pulse 58 bpm. Which nursing action/documentation best matches the section?

   1. Hold all HF medications for the shift without documenting hemodynamic assessment.
   2. Use clinical judgment and question whether the medication should be held because the pulse is less than 60 bpm.
   3. Base the decision only on the patient’s last daily weight and intake/output record.
   4. Administer the medication without further consideration because HF therapy centers on pharmacology.

   Answer: Use clinical judgment and question whether the medication should be held because the pulse is less than 60 bpm.

   The correct option applies the section’s direction to monitor response and use clinical judgment when the pulse is below 60 bpm. The other choices either ignore the hemodynamic finding, overgeneralize by holding everything, or rely on unrelated monitoring data alone.

7. At 2300, a nurse reviews the results for a patient admitted with acute left-sided HF: BNP was 500 pg/mL at 0800, 750 pg/mL at 1700, and 1500 pg/mL at 2300. Which documentation approach best supports evaluation of the patient's response to treatment?

   1. Record the latest BNP result and classify the treatment response from that result.
   2. Record current bedside findings and reserve the BNP trend for documentation of the diagnostic workup.
   3. Record all three BNP values alongside current respiratory findings, edema findings, and weight.
   4. Record the BNP trend alongside the admission assessment to describe the patient's current condition.

   Answer: Record all three BNP values alongside current respiratory findings, edema findings, and weight.

   The section recommends evaluating BNP levels together with the clinical presentation to assess treatment response. The latest value alone lacks clinical context, and the admission assessment may not represent the patient's current condition. Omitting the BNP trend from ongoing evaluation overlooks its role in monitoring response.

8. At 0800, a nurse reviewing an HF patient's chart notices that daily weights were obtained under different conditions. The nurse updates the care plan to make future weight measurements more comparable. Which instructions should be included? Select all that apply.

   1. Schedule weight measurement in the morning.
   2. Have the patient void before obtaining the weight.
   3. Use whichever garments the patient is wearing that morning.
   4. Use the same garments for weight measurements, or weigh the patient nude if possible.
   5. Weigh before the first morning void to capture the earliest value.

   Answer: Schedule weight measurement in the morning., Have the patient void before obtaining the weight., Use the same garments for weight measurements, or weigh the patient nude if possible.

   The section specifies morning weighing after voiding, with the patient in the same garments or nude if possible. Weighing before voiding or allowing garments to vary does not follow the stated approach to obtaining comparable daily weights.

9. At 1700, after auscultating a patient with HF who has a productive cough, a nurse reviews the entry 'Cough with abnormal breath sounds.' Which revision best addresses the missing assessment detail?

   1. Expand the note with sputum characteristics, using 'abnormal anterior and posterior lung sounds' to summarize auscultation.
   2. Expand the note with the locations of abnormal breath sounds, using 'productive cough' to summarize the sputum assessment.
   3. Expand the note with the locations of abnormal breath sounds and the sputum's color, consistency, and amount.
   4. Expand the note with oxygen saturation and breathing pattern, retaining 'cough with abnormal breath sounds' as the summary.

   Answer: Expand the note with the locations of abnormal breath sounds and the sputum's color, consistency, and amount.

   The section specifically calls for documenting where abnormal breath sounds are heard and the sputum's color, consistency, and amount. Adding oxygen saturation and breathing pattern does not supply those missing details. The other revisions leave either the sound locations or the sputum characteristics insufficiently described.

10. At 0700, a patient being evaluated for HF weighs three pounds more than yesterday morning. Both weights were obtained after voiding and in the same garments. Which entry best interprets this finding?

    1. Three-pound gain in 24 hours; the weight trend is not yet suggestive of HF because the five-pound weekly threshold has not been reached.
    2. Three-pound gain in 24 hours; this is suggestive of HF only if pitting edema is also present.
    3. Three-pound gain in 24 hours; this weight change is suggestive of HF.
    4. Three-pound gain in 24 hours; interpretation as an HF-related finding is deferred until BNP results are available.

    Answer: Three-pound gain in 24 hours; this weight change is suggestive of HF.

    The section identifies a three-pound gain in one day as suggestive of HF, independently of the five-pound weekly threshold. It does not require a BNP result or accompanying pitting edema before recognizing this weight change as a relevant finding.

11. At 0900, a nurse assesses a patient with HF and observes a productive cough with a small amount of frothy pink sputum. Crackles are heard at both posterior lung bases. Which entry best documents these respiratory findings?

    1. Productive cough with pink sputum; abnormal breath sounds present.
    2. Productive cough with a small amount of frothy pink sputum; crackles at both posterior lung bases.
    3. Small amount of frothy sputum observed; respiratory assessment consistent with pulmonary fluid retention.
    4. Crackles at the lung bases; sputum findings consistent with HF.

    Answer: Productive cough with a small amount of frothy pink sputum; crackles at both posterior lung bases.

    The correct entry records sputum color, consistency, and amount, together with the location of the adventitious sounds. The other entries omit observed details or replace them with a general interpretation, making the assessment less specific.

12. At 1900, a nurse reviews documentation for a patient receiving ordered diuretic therapy for HF. Blood pressure, pulse, lung sounds, and urine output are recorded, but today's weight and fluid intake are missing. Which actions address the gaps in documenting the patient's fluid response to therapy? Select all that apply.

    1. Complete strict intake and output documentation by including fluid intake.
    2. Use the recorded blood pressure and pulse as the fluid-response assessment without adding intake data.
    3. Obtain and document today's daily weight.
    4. Carry forward the previous weight because urine output has already been documented.
    5. Add the most recent ejection fraction as the measure of the current diuretic response.

    Answer: Complete strict intake and output documentation by including fluid intake., Obtain and document today's daily weight.

    The section specifically identifies daily weights and strict intake and output as measures of response to diuretic therapy. Blood pressure and pulse provide hemodynamic information but do not complete the missing fluid-response data. An ejection fraction or a carried-forward weight does not supply today's weight or complete the intake and output record.

13. At 2300, the nurse reviews the provided laboratory profile for a patient admitted with acute left-sided HF: BNP was 500 pg/mL at 0800, 750 pg/mL at 1700, and 1500 pg/mL at 2300. Which summary best interprets this trend for the nursing assessment?

    1. BNP is rising, consistent with the slight increase associated with age; document the trend primarily as an age-related variation.
    2. BNP is rising and establishes the patient's current condition; further clinical findings are unnecessary for interpreting the response to treatment.
    3. BNP is rising, consistent with increased myocardial stretch and pressure; interpret the trend alongside the patient's clinical findings.
    4. BNP is rising, indicating hepatic congestion; interpret the trend primarily as a liver function finding.

    Answer: BNP is rising, consistent with increased myocardial stretch and pressure; interpret the trend alongside the patient's clinical findings.

    The section links rising BNP to increased myocardial stretch and pressure and directs assessment of BNP alongside clinical presentation. A slight age-related increase does not adequately explain the rapid rise shown, and BNP does not replace clinical assessment. Hepatic congestion is discussed in relation to liver function tests, not as the primary interpretation of BNP.

14. At 0800, a patient with HF could lie flat comfortably, had no cough or extremity swelling, was alert and oriented, and completed activities of daily living without breathlessness. During the 1600 reassessment, which findings should the nurse flag in the assessment note as possible worsening HF? Select all that apply.

    1. A new productive cough with frothy pink sputum is observed.
    2. The patient's rings now feel tight, and new sock indentations are visible on the lower legs.
    3. The patient continues to complete activities of daily living without breathlessness.
    4. The patient remains alert and oriented at the established baseline.
    5. The patient now reports needing to sit upright in a recliner because lying flat makes breathing difficult.

    Answer: A new productive cough with frothy pink sputum is observed., The patient's rings now feel tight, and new sock indentations are visible on the lower legs., The patient now reports needing to sit upright in a recliner because lying flat makes breathing difficult.

    New difficulty breathing while lying flat, signs of fluid retention, and frothy pink sputum are changes consistent with the section's HF manifestations. The section identifies new deviations from the previous assessment as cues to possible complications or worsening disease. Unchanged baseline mentation and continued activity without breathlessness do not represent deterioration from the morning assessment.