Patient on enalepril and diuretic therapy for heart failure. Nurse should notify the Physician that the therapy is not effective when she finds

1. A

   Dry cough

2. B

   Skin rash

3. C

   Edema legs

4. D

   Postural fall in B.P.

Appeared in: JIPMER Nursing Officer-2017

Explanation

• The primary goal of diuretic and ACE inhibitor therapy in heart failure is to reduce fluid overload (preload) and the heart's workload (afterload).
• Leg edema is a cardinal sign of peripheral fluid retention due to the heart's inability to pump effectively.
• The presence of leg edema despite treatment indicates that the current medication regimen is insufficient to manage the fluid imbalance, signifying ineffective therapy.
• This finding requires the nurse to notify the physician for a potential adjustment in medication dosage or type.

Why Other Options Were Wrong

• Option A: A dry, nonproductive cough is a very common side effect of ACE inhibitors like enalapril, caused by increased levels of bradykinin.
• Option B: A skin rash is an adverse or allergic reaction to a medication.
• Option D: A postural fall in blood pressure (orthostatic hypotension) is an expected side effect of both diuretics (from volume loss) and ACE inhibitors (from vasodilation).

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Evaluation of therapeutic effectiveness for heart failure medications to guide bedside assessment, documentation, and the next nursing action.
• A key nursing responsibility in managing heart failure is the daily assessment for signs of fluid overload. This includes checking for peripheral edema, auscultating lung sounds, and monitoring daily weights.
• A weight gain of more than 2-3 pounds (about 1-1.5 kg) in 24 hours or 5 pounds (about 2.3 kg) in a week is a critical sign of fluid retention that must be reported immediately.
• What if the patient also reported increasing shortness of breath when lying down (orthopnea)? This would be another, more severe, sign of worsening fluid overload (pulmonary congestion) and ineffective therapy, requiring urgent intervention.

How to Approach the Question

• First, identify the core purpose of the medications mentioned. Enalapril (ACE inhibitor) and diuretics are used in heart failure to reduce the heart's workload and eliminate excess fluid.
• Next, analyze the question's prompt, which asks for a sign that this therapy is not effective.
• Evaluate each option: Does it represent a failure to achieve the therapeutic goal, or is it a known side effect or unrelated issue?
• Option A (cough) and D (low BP) are known side effects of the drugs, indicating they are active in the body.
• Option B (rash) is an adverse reaction, not related to efficacy.
• Option C (edema) directly contradicts the goal of eliminating excess fluid, making it the clear sign of ineffective therapy.

Concept Tested & Keywords

• Concept Tested: Evaluation of therapeutic effectiveness for heart failure medications.
• Stem keywords: enalapril, diuretic therapy, heart failure, therapy not effective
• Lead-in keywords: notify the Physician, not effective
• Negative lead-in flag: false

Question ID

Q-8PuiKYy3Mzl027CyLx9B

Copy ID

Reference Book

E6 Pharmacology Nursing Lilley 11e Part 2 pp. 75-77, 38-40

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 689-691