Heart Failure Case Studies with Detailed Answers for Nursing & Medical Students

On this page, you will find 10 case studies commonly tested in heart failure exams. Each case includes multiple questions with detailed answers and rationales to strengthen your clinical judgment. Practice each scenario several times to build confidence and mastery.

Before you begin, here is a quick refresher on essential heart failure concepts.

Overview of Heart Failure

Heart failure is a pathophysiologic condition in which the heart cannot pump enough blood to meet the body’s metabolic needs or can do so only with elevated filling pressures. It may result from myocardial dysfunction or occur during periods of increased demand, even when cardiac function is nearly normal. Although heart failure always leads to circulatory failure, circulatory failure can also occur independently in conditions like hypovolemic or septic shock.

To maintain cardiac output, the body increases blood volume, filling pressures, heart rate, and myocardial mass. These compensatory mechanisms help temporarily but eventually contribute to worsening cardiac dysfunction.

Common signs and symptoms include tachycardia, venous congestion with edema, fatigue from low output, and breathlessness—the hallmark of left ventricular failure.

NYHA Classification (by activity tolerance)

• Class I: No limitation of physical activity
• Class II: Slight limitation
• Class III: Marked limitation
• Class IV: Symptoms at rest

ACC/AHA Stages (by disease progression)

• Stage A: High risk, no structural disease
• Stage B: Structural disease, no symptoms
• Stage C: Structural disease with symptoms
• Stage D: Refractory heart failure requiring specialized interventions

(Newer terminology describes these as At Risk for HF, Pre-HF, Symptomatic HF, and Advanced HF.)

Diagnostic Evaluation

• CBC
• Electrolytes
• Liver and renal function tests
• Chest radiography
• ECG
• Echocardiography
• BNP or NT-proBNP to distinguish cardiac vs noncardiac dyspnea

Management Overview

Management of acute heart failure focuses on stabilizing the patient, identifying the cause, and providing therapies that improve symptoms and outcomes. Treatment options may include revascularization, arrhythmia management, CRT, ICDs, valve procedures, ventricular assist devices, and heart transplantation.

Pharmacologic therapy aims to relieve symptoms and improve survival. Oxygen, diuretics, digoxin, inotropes, and morphine may be used. Medications known to worsen heart failure — such as NSAIDs, certain calcium channel blockers, and some antiarrhythmics — should be avoided.

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Case Studies in Heart Failure with Questions and Answers

Case Study 1: M.G. Heart Failure Diagnosis

M .G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure (HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can't catch my breath and my legs are as big as tree trunks.” After further questioning, you learn that she is strictly following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds every day since her discharge.

This case study was extracted from Winningham's Critical Thinking Cases in Nursing

1. What error in teaching most likely occurred when M.G. was discharged 10 days ago?

Answer: A breakdown of successful communication occurred regarding when to call with early weight gain. It is imperative that patients understand when to call their provider after being discharged from the hospital for exacerbated HF. Comprehensive patient education starting at admission is considered a standard of care and is mandated by The Joint Commission when care is provided to hospitalized patients. The goal of the discharge treatment plan is to facilitate successful patient self-management, minimize symptoms, and prevent readmission.

During the admission interview, the nurse makes a list of the medications M.G. took at home.

Nursing Assessment: Medications Taken at Home
Enalapril (Vasotec)	5 mg PO bid
Pioglitazone (Actos)	45 mg PO every morning
Furosemide (Lasix)	40 mg/day PO
Potassium chloride	20 mEq/day PO

2. Which of these medications may have contributed to M.G.'s HF? Explain.

Answer: Thiazolidinediones, such as pioglitazone, may increase the risk of HF and should not be used in patients with symptoms of HF. They commonly cause peripheral edema and weight gain (which are the result of both water retention and increased deposit of adipose tissue).

3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce HF? Select all that apply. ACE inhibitors:

a. Prevent the conversion of angiotensin I to angiotensin II.

b. Cause systemic vasodilation.

c. Promote the excretion of sodium and water in the renal tubules.

d. Reduce preload and afterload.

e. Increase cardiac contractility.

f. Block sympathetic nervous system stimulation to the heart.

Answers: a, b, d

ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor.

This results in systemic vasodilation, thereby reducing preload (reducing the volume of blood entering the left ventricle) and afterload (reducing the resistance to the left ventricular contraction) in patients with HF. ACE inhibitors do not promote the excretion of sodium and water, and they do not cause increased cardiac contractility or block the sympathetic nervous system to the heart.

Also Practice: Cardiovascular Questions to Expect on Your Pathophysiology Exam

After reviewing M.G.'s medications, the physician writes the following medication orders.

Medication Orders
Enalapril (Vasotec)	5 mg PO bid
Carvedilol (Coreg)	3.125 mg PO twice daily
Glipizide (Glucotrol)	10 mg PO every morning
Furosemide (Lasix)	80 mg intravenous push (IVP) now, then 40 mg/day IVP
Potassium chloride (K-Dur)	20mEq/day PO

4. What is the rationale for changing the route of the furosemide (Lasix)?

Answer: M.G. is fluid overloaded and needs to decrease fluid volume in a short period. Intravenous administration is delivered directly into the vascular system, where it can start to work immediately. In HF, blood flow to the entire gastrointestinal (GI) system is compromised; therefore the absorption of orally ingested medications may be variable and take longer to work.

5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you would use to monitor the effectiveness of this medication.

• Increased urine output

• Daily weight, looking for weight loss

• Intake and output (I&O)

• Decreased dependent edema

• Decreased shortness of breath, diminished crackles in the bases of the lungs, decreased work of breathing, and decreased O2 demands

• Decreased jugular venous distention (JVD)

4. What laboratory tests should be ordered for M.G. related to the order for furosemide (Lasix)? Select all that apply.

a Magnesium level

b Sodium level

c Complete blood count (CBC)

d. Serum glucose level

e Potassium level

f Coagulation studies

Answers: a, b, d, e

Furosemide is a potent diuretic, especially when given via IVP, and may cause the loss of electrolytes such as magnesium, sodium, and potassium. These electrolytes will need to be supplemented if the levels are low. In addition, furosemide may increase serum glucose levels, which is an issue, considering that M.G. has diabetes. It is not necessary to monitor CBC or coagulation studies while the patient is on furosemide.

Answers for the remaining parts of this case study can be found in the Solution Manual for Winningham’s Critical Thinking Cases in Nursing, 6th Edition. Download it today and practice similar case studies in heart failure, hypertension, coronary artery disease, and many other cardiovascular conditions included in the solution manual and test bank.

7. What is the purpose of the beta blocker carvedilol? It is given to:

a. increase the contractility of the heart.

b. cause peripheral vasodilation.

c. increase urine output.

d. reduce cardiac stimulation from catecholamines.

8. You assess M.G. for conditions that may be a contraindication to carvedilol. Which condition, if present, may cause serious problems if the patient takes this medication?

a. Angina

b. Asthma

c. Glaucoma

d. Hypertension

One day later, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added to her orders.

9. What is the action of the digoxin? Digoxin:

a. causes systemic vasodilation.

b. promotes the excretion of sodium and water in the renal tubules.

c. increases cardiac contractility and cardiac output.

d. blocks sympathetic nervous system stimulation to the heart.

10. Which findings from M.G.'s assessment would indicate an increased possibility of digoxin toxicity? Explain your answer.

a. Serum potassium level of 2.2 mEq/L

b. Serum sodium level of 139 mEq/L

c. Apical heart rate of 64 beats/minute

d. Digoxin level 1.6 ng/mL

11 When preparing to give the digoxin, you notice that it is available in milligrams (mg) not micrograms (mcg). Convert 125 mcg to mg.

12. M.G.'s symptoms improve with intravenous diuretics and the digoxin. She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate for achievement of a euvolemic state. What will determine whether the oral dose will be adequate for discharge to be considered?

13. M.G. is ready for discharge. According to the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission?

14. After the teaching session, which statement by M.G. indicates a need for further education?

a. “I will weigh myself daily and tell the doctor at my next visit if I am gaining weight.”

b. “I will not add salt when I am cooking.”

c. “I will try to take a short walk around the block with my husband three times a week.”

d. “I will use a pill calendar box to remind me to take my medicine.”

Case Study 2: Mark Patient with Type 2 Diabetes

Mark, a 59-year-old with type 2 diabetes for 7 years, came to see his GP reporting increased breathlessness on exercise, ankle swelling and general fatigue (but no chest pain) over the previous 2 months. Examination revealed pulse 78 beats/min regular, blood pressure 132/67 mmHg, heart sounds normal with no added sounds or murmurs, bilateral inspiratory crackles on the lung bases, and bilateral ankle oedema.

Solution:

Mark’s symptoms are most consistent with heart failure, most likely diastolic heart failure (HFpEF) secondary to long-standing type 2 diabetes.

Reasoning:

• Dyspnea on exertion and fatigue: reduced cardiac output or pulmonary congestion
• Bilateral ankle edema: fluid retention, typical of heart failure
• Basal crackles on lung exam: pulmonary congestion
• No chest pain or murmurs: less likely acute coronary syndrome or valvular heart disease
• History of diabetes: increases risk of diabetic cardiomyopathy, leading to stiff ventricles and diastolic dysfunction

Rationale: Long-standing diabetes can cause the heart muscle to become stiff (diastolic dysfunction), leading to fluid buildup in the lungs and legs without necessarily reducing the ejection fraction. Mark’s presentation of fatigue, breathlessness, ankle swelling, and basal crackles fits this pattern.

Question 1:

Which investigations would you order to confirm the diagnosis of heart failure in Mark and why?

Answer:

Key investigations for suspected heart failure include:

1. Echocardiography – to assess left ventricular ejection fraction (LVEF), diastolic function, and structural heart disease.
2. BNP or NT-proBNP levels – elevated levels support a diagnosis of heart failure.
3. Chest X-ray – may show pulmonary congestion, cardiomegaly, or pleural effusions.
4. ECG – to detect arrhythmias, prior myocardial infarction, or ischemic changes.
5. Blood tests – renal function, electrolytes, and thyroid function to rule out secondary causes and guide therapy.

Rationale:

• Mark’s symptoms (dyspnea, edema, crackles) suggest heart failure.
• Echocardiography differentiates HFrEF vs HFpEF, important in diabetics.
• BNP helps confirm cardiac vs non-cardiac causes of dyspnea.

Question 2:

Which type of heart failure is Mark most likely experiencing, and what is the pathophysiological mechanism?

Answer: Most likely: Diastolic heart failure (HFpEF), secondary to long-standing type 2 diabetes.

Pathophysiology:

• Chronic diabetes: myocardial stiffness and impaired ventricular relaxation.
• During diastole, the ventricle cannot fill adequately, increasing filling pressures.
• This leads to pulmonary congestion (basal crackles) and peripheral edema (ankle swelling), even with preserved ejection fraction.

Rationale:

• Preserved BP and normal heart sounds make systolic dysfunction less likely.
• Diabetes is a common cause of HFpEF through diabetic cardiomyopathy.

Question 3:

List three non-pharmacological strategies Mark can use to manage his heart failure symptoms.

Answer:

1. Sodium (salt) restriction – helps prevent fluid retention and reduce edema.
2. Fluid restriction – in patients with volume overload to control congestion.
3. Regular physical activity – light exercise as tolerated improves functional capacity and reduces fatigue.

Rationale:

• Lifestyle modifications complement pharmacologic therapy.
• Reducing sodium and fluids helps prevent worsening edema and dyspnea.
• Exercise, under medical guidance, improves cardiac efficiency and quality of life.

Case Study 3: Care and management of heart failure

A 66-year-old client has been in the hospital for care and management of heart failure. There are orders for discharge and the nurse is reviewing discharge instructions with the client.

Which of the following information would be included as part of discharge information for this client?

• A The client should not eat more than 2,000 mg of sodium each day
• B The client should restrict fluid intake to less than 4,000 mL per day
• C The client should not have more than 3 alcoholic beverages per day
• D The client should take non-steroidal anti-inflammatory drugs (NSAIDs) for pain control and not acetaminophen

Correct Answer is A: The client should not eat more than 2,000 mg of sodium each day

RATIONALE

Sodium restriction

Excess sodium intake can cause changes in circulatory volume, potentially increasing fluid and contributing to buildup. Many clients with heart failure are restricted in their dietary sodium to 2,000 mg a day, although in some cases, the provider may allow for more or less, depending on the client's condition.

Alcohol Intake

While a client with heart failure may drink alcohol, it must be done in moderation. Three alcoholic beverages per day is too much alcohol, and would be considered moderate to heavy drinking. A client with heart failure should be counseled not to drink more than one alcoholic beverage in a day, and to avoid drinking alcohol every day.

Non-Steroidal Anti-Inflammatory Drugs

NSAIDS may worsen heart failure and should be avoided.

Fluid restriction

Heart failure can cause an increase in fluid in the circulatory system. Most heart failure clients are instructed to restrict fluid to 1,000 to 2,000 mL per day.