Scenario #1 A 74-year-old female patient was admitted from home with progressive increase in breathlessness, orthopnea and ankle edema over the previous 3 weeks. Her general practitioner had...

Scenario #1
A 74-year-old female patient was admitted from home with progressive increase in breathlessness, orthopnea and ankle edema over the previous 3 weeks. Her general practitioner had prescribed oral metoprolol and spironolactone. She had also suffered from dyspepsia, increasing over recent weeks, and the general practitioner noted a new murmur.
She was tachypneic (25 breaths/min); with a low volume pulse. Sitting blood pressure was 110/70 mm Hg. The apex beat was in the anterior axillary line and a parasternal lift was prominent. A pansystolic murmur was audible and late inspiratory crackles were heard throughout both lung fields. There was sacral edema.
The ECG confirmed sinus tachycardia (110 beats min−1) with antero-lateral Q waves of previous infarction and the chest X-ray confirmed cardiomegaly and interstitial edema. Routine chemistry showed Na+ 128; K+ 5.8; BUN 19; creatinine 1.5. A creatine kinase series was unremarkable. Echocardiography showed a dilated heart with anterior and septal hypokinesis and apical dilatation compatible with previous anterior infarction. The posterior wall was contracting vigorously. A high velocity jet (4.7 m s−1) of mitral regurgitation was noted but the left atrial size was normal.
1. What type of heart failure is this?  a. Left b. Right c. Dilated cardiomyopathy d. Hypertrophic cardiomyopathy
2. Which symptoms indicate heart failure? a. Tachypnea and murmur b. Dyspnea and dilated heart c. K+ of 5.8 and Blood Pressure of 110/70 d. Tachycardia and tachypnea
3. What is the most likely cause of this patient’s heart failure? (Select all that apply) a. Congenital disease b. Cocaine use c. Valvular heart disease d. Past MI e. Systolic murmur
4. What is the most urgent nursing priority? a. Decrease the potassium level to reduce the risk for fatal dysrhythmia b. Call physician to request a beta blocker c. Diurese to improve breathing d. Mitral valve replacement surgery prep
5. Which complications would a nurse assess for? (Select all that apply) a. Increased Creatinine indicating worsening perfusion of the kidneys b. Decreased heart rate related to increasing the metoprolol dose c. Retroperitoneal bleed at the left femoral artery after the echocardiogram

d. Atrial fibrillation resulting in increased dizziness
6. What tests would you expect to be ordered? (Select all that apply) a. Chest x-ray b. Repeat labs including BNP c. Repeat echo d. Daily weights
7. What teaching would you provide for the patient at discharge? a. Daily weights, hourly input and output, 4 g sodium diet b. Decrease dark green, leafy vegetables, increase activity and monitor INR c. Pursed lip breathing, 2 g sodium diet and decrease fluid intake d. Medication organization and timing, daily weights, increase activity
Scenario #2 This 76-year-old man with known mitral regurgitation is referred for heart failure management. Three years ago he had an inferior wall myocardial infarction that was not recognized at the time. Since then he has had dyspnea on exertion. One month ago he had a hospital admission for decompensated heart failure. Currently he has NYHA Class III symptoms on his medical regimen. Medical History  COPD on home oxygen, 2 liters by nasal cannula.  S/P CVA 5 years ago with mild residual left lower extremity