Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.  
A 67-year-old man with a five-year history of heart failure with reduced ejection fraction presented to the E.R. about seven days ago with worsening shortness of breath and new onset orthopnea. He was hospitalized for two days with medications adjusted and stated at that time, his symptoms were significantly improved. The NP now sees him in follow-up. The patient states today that for the past day, “I feel just like I did the day I was admitted to the hospital. I might even be worse.” The patient reports a 5-pound weight gain since arriving at home from the hospital. He denies dietary indiscretion with high sodium foods and states he's taking all medications prescribed at the hospital discharge as advised. On physical exam, he's sitting upright, has slightly labored breathing, his BP is 165/92, resting heart rate 110 with an S3 heart sound, respiratory rate of 26, neck veins distended to 8 centimeters, and bilateral crackles throughout the lung fields. The most appropriate next step in his care is to:

A. Perform medication reconciliation.
B. Obtain a detailed 48-hour dietary and fluid intake history.
C. Advise for the need for evaluation and treatment in the emergency department.
D. Ensure he has a cardiology follow-up in the next week.

Where do we start?

Well, as we have with other Q&A podcasts, let's take a look at the question and determine what it focuses on—assessment, diagnosis, plan, or evaluation. But I'm going to do things a little bit differently in this question, and I'll reveal once we go through the breakdown of the question, the key components, and I'm even going to hold off on giving you the correct answer for a moment here. I want you to think like nurse practitioners, as you are now the primary assessing provider, the provider that will come up with the diagnosis, a provider that will adjust the plan of care, and the provider that evaluates response to care.

Some background information first on heart failure and this patient in particular. We're told this is an older adult with a reduced ejection fraction heart failure for a number of years. We're not given his ejection fraction. But, you know, that's actually okay. What we should know is and this would be part of you're walking around information, is that if he has reduced EF failure, then his left ventricular ejection fraction is less than 40%. In a healthy heart, the ejection fraction is usually between about 50 to 75%. Heart failure occurs as a result of altered cardiac function that leads to inadequate cardiac output resulting in instability to meet the oxygen and metabolic demands of the body. The underlying cause is usually changes in cardiac structure leading to diastolic and or systolic dysfunction. Hypertensive heart disease and atherosclerosis are the leading causes of heart failure. Now, this person in particular, is having an acute exacerbation of heart failure a week ago, and now we're being told he got better and now he's gotten worse again. We're looking at the clinical presentation of an acute exacerbation of heart failure, one of the most common reasons for acute care hospital admission. This can include unexplained weight gain. He's gained 5 pounds in since he got home from the hospital. And what this is going to require you to do is do the math, if you will. He was hospitalized seven days ago from the time you're seeing him. He was in the hospital for two days, which means he's been home for five days. So, in other words, 5-pound weight gain in five days. And he also has worsening dyspnea from baseline.

With heart failure exacerbation, the S3 heart sound is usually noted, and this is the sound of systolic dysfunction typically disappearing on resolution of whatever the acute event was. Of course, additional findings can include diaphoresis, lower extremity or dependent edema, pallor, complaints of orthopnea or paroxysmal dyspnea. By the way, if those last two terms, orthopnea and paroxysmal nocturnal dyspnea, are unfamiliar to you, you need to include looking those up and having a working definition of both for your knowledge base. Sometimes I will hear from people who didn't do well on boards and they'll say, I need more vocabulary. I encountered words I wasn't familiar with. These are words that you should at this level of your practice, be quite familiar with.

So back to the question. Keep in mind, that this is a question about a patient feeling poorly. About a week ago, as I said, went to the E.R., admitted for two days, and that tells us he was pretty sick, if he was kept for two days, and then after two days, he was more physiologically stable. That's why he went home and now felt okay for four days. But now the past day, he has felt poorly again. So, analyzing and synthesizing this HPI information is critical for arriving at the best answer.

Let's take a look at the question and the given responses.

A 67-year-old man with a five-year history of heart failure with reduced ejection fraction presented to the E.R. about seven days ago with worsening shortness of breath and new onset orthopnea. He was hospitalized for two days with medications adjusted and stated at that time, his symptoms were significantly improved. The NP now sees him in follow-up. The patient states today, “For the past day I feel just like I did the day I was admitted to the hospital. In fact, I might feel even worse.” The patient reports a 5-pound weight gain since arriving home from the hospital. He denies dietary indiscretion with high-sodium foods and states he's taking all his medications prescribed at the hospital as advised. On physical exam, he's sitting upright, slightly labored breathing. BP 165/ 92, his resting heart rate is 110 with an S3 heart sound present. Respiratory rate 26, neck veins distended to 8 cm. He has bilateral crackles through the lung fields. The most appropriate next step in his care is to:

Perform med reconciliation. This is incorrect. While of course, med reconciliation is a critical part of seeing a patient post-hospitalization, particularly when they've had significant physiologic instability, such as he has with heart failure, this ignores the fact that the patient right now in your exam room is in crisis. I appreciate we're all so well attuned to do med rec, but what we can't do is say that that's more important than assuring a physiologically unstable patient gets appropriate care.
Obtain a 48-hour dietary and fluid intake history. Again, that's incorrect. When looking at this patient's recent history, certainly a detailed history of his dietary intake, particularly to unearth high sodium foods that he might not appreciate he's taking in. Right now, the scenario is we have a really unstable patient in the exam room of a primary care office. He simply needs to be transported quickly to a higher level of care.
Advise on the need for evaluation and treatment in the emergency department. This is the best answer. As I've mentioned, the patient is physiologically unstable, showing us that he's right back to where he was a week ago with his heart failure when he went to the E.D. And in fact, the patient says I might even feel worse. He went home from the hospital, was stable for a few days, and now suddenly he is in much rougher shape. So, this question appears to be, on the surface, an assessment question where you'd gather more information. Because I read this scenario and I say, Yeah, but I want more about his meds. I want more about what he ate. Yes, yes, yes. That's all important. But that's reflected in options A and B. It's more a plan slash intervention question, where you’re being asked to assess the patient, you deem the patient to be physiologically unstable and in need of a higher level of care, therefore, acting promptly is called for. Get him to the E.R.
Ensure he has a cardiology follow-up within the next week. Obviously, that's incorrect because C is the best. Yes, he does need cardiology follow-up, but one more time, it ignores the fact that he's really quite sick now.

Key takeaway: Keep in mind, when all is said and done, what you need to do is get back to A, B, C: airway, breathing, and circulation. A patient's physiologic stability takes precedence over all other clinical priorities.

Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit FHEA.com 