HESI Case study Heart Failure with Atrial Fibrillation Jonathan Stevens

In addition to these two risk factors, which question will provide the nurse the best data about any additional risk factors for heart failure? "Do you have any chronic lung disorders?" "Have you ever had a heart attack?" "Do you have varicose veins?" "Have you ever had low blood pressure?"

"Have you ever had a heart attack?" Myocardial infarction, coronary artery disease, and ischemic heart disease are among the most common underlying causes of heart failure. In fact, the most common cause of heart failure is myocardial infarction. The nurse should also ask Jonathan if he has hypertension, another primary underlying condition causing heart failure.

What is the best response by the nurse? What is the best response by the nurse? "I'm glad to see you are getting some rest." "Don't you have someone to sit with you?" "Acting so depressed will not help your father." "You are going through a very difficult time."

"You are going through a very difficult time." Acknowledging that an individual is going through a difficult experience is an effective therapeutic technique that encourages continued communication.

The nurse prepares a dose of digoxin (Lanoxin) 0.125 mg via IV push. The medication is supplied as 0.25 mg in 2 mL. How many mL should the nurse prepare to give? (Enter numeric value only. If rounding is necessary, round to the whole number.)

1 D/H x V = X 0.125 mg divided by 0.25 mg times 2 mL = 1 mL

Based on Jonathan's cardiac dysrhythmia, which action should the nurse implement first? Based on Jonathan's cardiac dysrhythmia, which action should the nurse implement first? Administer a prescribed stat dose of digoxin (Lanoxin). Notify the health care provider of the dysrhythmia. Transfer Jonathan to the Medical Intensive Care Unit. Prepare for synchronized cardioversion.

Administer a prescribed stat dose of digoxin (Lanoxin). If a dose of digoxin has already been prescribed, it should be administered before taking further action. Digoxin slows the heart rate and increases the force of the heart's contraction, which is very useful in the treatment of Jonathan's type of cardiac dysrhythmia.

Which member of the nursing staff would be best assigned to Jonathan while he is receiving treatment for his digitalis toxicity? An LPN from an agency pool who states that he has 5 years of med-surg experience. An LPN who has worked on the Cardiac Observation Unit for the last 2 years. A new graduate RN who has just completed a 4-week orientation on the unit. An experienced critical care RN who has been assigned to "float" on the unit.

An experienced critical care RN who has been assigned to "float" on the unit. This is the best assignment, since Jonathan requires the assessment skills and clinical judgment abilities of an experienced RN.

Which manifestations are early indications of digitalis toxicity? Hypertension and dizziness. Anorexia, nausea, and vomiting. Weight gain and fluid retention. Blurred vision and halo vision.

Anorexia, nausea, and vomiting. Gastrointestinal (GI) symptoms are among the earliest symptoms of digitalis toxicity, along with confusion and fatigue. Additional manifestations include headache, hypotension, and cardiac dysrhythmias.

Jonathan has been taking alpha-adrenergic blocker carvedilol (Coreg) 3.125 mg orally, twice a day. What information is most important for the nurse to provide to Jonathan? Select all that apply Avoid abrupt transitions to an erect posture. Full antihypertensive effect noted in 4 weeks. Take with food, and restrict salt and alcohol intake. Do not quickly discontinue the medication. Do not take extra medicine to make up a missed do

Avoid abrupt transitions to an erect posture. This is the most serious adverse response to the alpha-adrenergic blockade. Orthostatic hypotension can reduce blood flow to the brain, thereby causing dizziness, light-headedness, and even syncope (fainting). Take with food, and restrict salt and alcohol intake. Carvedilol works best if you take it with food. Do not quickly discontinue the medication. Stopping the medication suddenly may make the condition worse. Do not take extra medicine to make up a missed dose. The dose should be taken as soon as the client remembers. If it is too close to the next dose, then the medication should be skipped.

Which assessment is most important for the nurse to perform prior to the administration of captopril (Capoten)? Apical pulse. Blood pressure. Respiratory rate. Intake and output.

Blood pressure. Capoten is an angiotensin converting enzyme (ACE) inhibitor used as an antihypertensive agent. ACE inhibitors have been shown to prolong survival in clients with heart failure. By lowering the blood pressure (reduced afterload), the workload on the heart is reduced. The nurse should monitor Jonathan's blood pressure to ensure that the medication is having the desired effect, and that hypotension does not occur.

How would this reading be interpreted by the nurse? How would this reading be interpreted by the nurse? Respiratory alkalosis. Metabolic acidosis. abolic alkalosis Respiratory acidosis.

Respiratory acidosis. Respiratory acidosis is diagnosed with the PaCO2 is high and the pH is low.

What additional instruction(s) should the nurse include in Jonathan's teaching plan? Select all Monitor blood pressure prior to administration of digoxin (Lanoxin). Immediately report a cold or sore throat to your health care provider. If a dose of digoxin (Lanoxin) is missed, double the next dose. Do not stop taking any prescribed potassium supplements. Regular blood draws will be necessary to measure prothrombin time (PT) and INR.

Do not stop taking any prescribed potassium supplements. This is especially important if the client is taking a loop diuretic, which causes a loss of potassium. Remember, hypokalemia contributes to digitalis toxicity. Regular blood draws will be necessary to measure prothrombin time (PT) and INR. Jonathan is taking Coumadin. PT and INR must be monitored regularly to ensure accurate dosing and prevent complications such as bleeding or clotting

Which assessment finding would indicate to the nurse that Jonathan is experiencing right-sided heart failure? Dyspnea. Tachycardia. Edema. Fatigue.

Edema. Right-sided heart failure results in peripheral congestion due to the inability of the right ventricle to effectively pump blood out of the heart to the lungs, causing edema, JVD, an enlarged liver, abdominal ascites, and weight gain.

Which action should the nurse implement first? Which action should the nurse implement first? Notify the respiratory therapist. Assist Jonathan to turn on his side. Elevate the head of Jonathan's bed. Offer Jonathan a back massage.

Elevate the head of Jonathan's bed. Since the nurse knows that Jonathan is already experiencing impaired gas exchange and is now obviously dyspneic, the first priority is to reduce the impaired gas exchange. The nurse should first elevate the head of the bed and assist Jonathan with deep breathing to promote improved oxygenation. Oxygen saturation should be monitored via pulse oximetry, and supplemental oxygen should be provided to maintain adequate oxygenation. Additional assessment includes breath sounds, respiratory rate, rhythm, and effort.

Which intervention should be implemented based on the diagnosis of activity intolerance? Which intervention should be implemented based on the diagnosis of activity intolerance? Provide 3 large meals daily. Provide all activities of daily living (ADLs) for the client. Encourage frequent rest periods. Encourage regular aerobic exercise.

Encourage frequent rest periods. The nurse should implement measures that promote rest, such as providing adequate rest periods and assessing the need for a hypnotic medication at bedtime. In addition, the nurse should implement measures that will reduce the client's energy expenditure, such as assisting with transfers and ADLs.

What imbalance places the client taking digoxin (Lanoxin) at greatest risk of toxicity and associated dysrhythmias? Anemia. Leukocytosis. Hypercalcemia. Hypoalbuminemia.

Hypercalcemia. Calcium binds with digitalis to decrease the effects of digitalis. In addition, hypercalcemia can cause depressed cardiac activity, dysrhythmias, and cardiac arrest. Along with serum calcium levels, the nurse should also monitor serum magnesium levels. Hypomagnesemia is also a contributing factor to digitalis toxicity, and it can cause dysrhythmias, hypotension, and tachycardia.

Which nursing diagnosis should be included in the plan of care? Fluid volume deficit. Ineffective airway clearance. Altered nutrition, greater than needs. Impaired gas exchange.

Impaired gas exchange. As the lung tissues become congested with fluid, less oxygen is available for exchange, resulting in diminished tissue oxygenation. Additional high priority diagnoses include decreased cardiac output and activity intolerance.

Jonathan is now on Furosemide (Lasix) 20 mg orally, twice a day. Jonathan is aware that this medication increases his urinary output. He asks the nurse how Lasix helps his heart. What topic information should be included in the nurse's response? Select all that apply Jonathan is now on Furosemide (Lasix) 20 mg orally, twice a day. Jonathan is aware that this medication increases his urinary output. He asks the nurse how Lasix helps his heart. What topic information should be included in the nurse's response? It reduces fluid in the body. It improves cardiac conductivity. It increases venous vasodilatation. Lasix reduces oxygen demand. It helps to lower blood pressure. Case Study Details

It reduces fluid in the body. Ventricular fibers contract less forcefully when they are overstretched, such as in a failing heart. Interventions aimed at reducing preload, attempt to decrease volume and pressure in the left ventricle, optimizing ventricular muscle stretch and contraction. Common drugs prescribed to reduce preload are diuretics and venous vasodilators. High-ceiling (loop) diuretics, such as furosemide (Lasix), is most effective for treating fluid volume overload Lasix reduces oxygen demand. Reducing the workload of the heart by reducing cardiac preload, will reduce, not promote the heart's consumption of oxygen. It helps to lower blood pressure. Thiazide diuretics lower blood pressure, which reduces the risk of stroke and heart attack.

What is the first resource Madison and the nurse should consider during this decision-making process? The nursing code of ethics. The hospital's attorney. Jonathan's advance directive. Jonathan's case manager.

Jonathan's advance directive. A client's advance directive provides information about the client's wishes for life-saving procedures and support measures. This is the best resource to help Madison and the nurse to determine the course of action that Jonathan would want if he were able to make a decision at this time.

What is the best nursing action in response to this decision? Notify the health care provider of Madison's wishes. Notify the hospital supervisor of Madison's wishes. Write a "DNR per family wishes" order. Verbally report Madison's decision during shift report.

Notify the health care provider of Madison's wishes. Do not resuscitate (DNR) orders must be written by the health care provider to be legally binding.

What is the most important intervention for the nurse to implement? Assess the consistency and amount of the diarrhea. Obtain a serum potassium level. Obtain a prescription for an analgesic for Jonathan's headache. Instruct Jonathan to withhold the next daily dose of aspirin.

Obtain a serum potassium level. Jonathan is exhibiting signs of digitalis toxicity and hypokalemia (low potassium). The nurse should immediately obtain significant laboratory values, including serum potassium and digitalis levels. Hypokalemia potentiates the effect of digitalis and can result in digitalis toxicity. Serum potassium levels should range between 3.5 to 5.0 mEq/L. If the potassium value is 3.0 or less, the nurse should withhold the dose of digitalis, and notify the health care provider.

Which intervention should the nurse initiate first? Which intervention should the nurse initiate first? Obtain an oxygen saturation level via pulse oximeter. Call the lab to obtain a stat serum potassium level. Collect a sputum specimen for culture and sensitivity. Initiate suctioning to remove lung secretions.

Obtain an oxygen saturation level via pulse oximeter. The first priority is to ensure adequate oxygenation. Jonathan is exhibiting symptoms of pulmonary edema, which results in compromised oxygenation, requiring immediate action by the nurse.

Which electrolyte should be closely monitored in just a few hours after treatment with Digibind? Which electrolyte should be closely monitored in just a few hours after treatment with Digibind? Calcium. Potassium. Magnesium. Phosphate.

Potassium. A precipitous drop in serum potassium may occur after treatment with Digibind.

The nurse explains to Jonathan that docusate sodium (Colace) has been prescribed for what purpose? Prevent retention of excess body fluid. Maintain sufficient sodium intake. Prevent straining during a bowel movement. Strengthen the heart beat.

Prevent straining during a bowel movement. Colace is a laxative/stool softener that is administered to prevent constipation and straining at stool. A client with cardiac problems should be instructed to avoid use of the Valsalva maneuver (bearing down) to prevent vagal stimulation which may result in bradycardia. The nurse should assess bowel sounds and bowel activity daily to ensure the Colace is effective.

Which of these diagnostic tests is used to measure the pressure within the right atrium? Chest x-ray. Electrocardiograph. Echocardiography. Pulmonary artery catheterization.

Pulmonary artery catheterization. Pulmonary artery catheters are used in the management of acutely ill clients in the critical care setting. Catheterization allows measurement of the pressures within the right atrium and pulmonary artery, which then guides treatment. Case Study Details

Meet the Client: Jonathan StevensSixty-three-year-old Jonathan Stevens visits the healthcare clinic complaining of increasing fatigue and difficulty breathing. Physical assessment findings include a rapid, irregular heart rate of 138 beats/min, BP of 140/86 mmHg, and a respiratory rate of 28 breaths/min. His breath sounds are clear with fine crackles in the bases bilaterally. He has positive jugular vein distention (JDV) bilaterally and 1+ pitting edema of his ankles bilaterally. His initial medical diagnosis is heart failure (HF). Jonathan is immediately admitted to the acute care facility for further evaluation and treatment.

Risk Factors Heart failure occurs most commonly in clients over the age of 60, and occurs more commonly in males than females.

Which menu selection by Jonathan indicates that effective teaching has taken place? Canned tomato soup and a bologna sandwich on whole wheat bread. Roasted potatoes, fresh green beans, and grilled chicken seasoned with lemon. Sliced ham, rice seasoned with salt substitute, and canned fruit cocktail. Cheeseburger, french fries, cookies, and a milkshake.

Roasted potatoes, fresh green beans, and grilled chicken seasoned with lemon. Clients on restricted sodium diets should be encouraged to use seasonings such as lemon, herbs, and garlic instead of salt. Since restricting potassium is not a concern for Jonathan, the use of a salt substitute (which is high in potassium) can also be included in his diet

The nurse assesses for which expected outcome of digoxin (Lanoxin) therapy? Serum digoxin level of 1.0 ng/mL. Serum potassium level of 4.5 mEq/L. Apical-radial pulse deficit. S1, S2, S3, and S4 heart sounds present.

Serum digoxin level of 1.0 ng/mL. The therapeutic level of digoxin is 0.5 to 2.0 ng/mL. Jonathan was started on a loading dose of digoxin to reach a therapeutic level as quickly as possible. Levels greater than 2.4 ng/mL are considered toxic. Any client receiving digitalis should be monitored carefully for symptoms of digitalis toxicity.

Jonathan will be going home on Capoten 12.5 mg orally, twice a day. What information is most important for the nurse to include in the discharge teaching and document in the electronic medical record (EMR)? Jonathan will be going home on Capoten 12.5 mg orally, twice a day. What information is most important for the nurse to include in the discharge teaching and document in the electronic medical record (EMR)? Development of cough. Signs of angioedema. Loss or altered taste. Fever and joint pain.

Signs of angioedema. The most serious adverse effects of captopril and other ACE inhibitors are angioedema and acute renal failure. Angioedema is manifested by facial, perioral, epiglottal and/or extremity swelling, intestinal pain, and/or difficulty breathing and may occur at any time during therapy.

If Jonathan had not provided an advance directive, who should be consulted next, with regard to helping Madison make the best decision regarding Jonathan's care? Select all that apply Social worker. Clergy person. Healthcare providers. Hospital medical ethics committee. Hospital administrators.

Social worker. The social worker is an integral part of the team, and should be consulted regarding end of life decisions. Clergy person. The clergy person is an integral part of the team, and should be consulted regarding end of life decisions. Healthcare providers. The health care providers are an integral part of the team, and should be consulted regarding end of life decisions. Hospital medical ethics committee. The ethics committee is an excellent resource, and should always be consulted regarding end of life decisions.

What is the best nursing action in response to Madison's behavior? Stay seated next to Madison and remain quietly attentive. Turn on the television to provide Madison a distraction. Provide Madison with teaching pamphlets on pulmonary edema. Leave the waiting room quietly to show respect for Madison and give her some privacy.

Stay seated next to Madison and remain quietly attentive. Silence and offering one's presence are effective therapeutic techniques to encourage communicati

What is the most important intervention that Jonathan can perform at home, in an effort to monitor his heart failure? What is the most important intervention that Jonathan can perform at home, in an effort to monitor his heart failure? Check his radial pulse 6 times a day, upon arising, at each meal, and before bed. Wear loose clothing to bed at night. Weigh himself every day on the same scale. Begin a yoga regimen as soon as he gets home.

Weigh himself every day on the same scale. Daily weights are the most important intervention for monitoring heart failure. Clients should be instructed to call the HCP immediately with a weight gain of 2 to 3 lbs in 24 hours.

Which cardiac dysrhythmia is Jonathan most likely experiencing? Which cardiac dysrhythmia is Jonathan most likely experiencing? Sinus tachycardia. Atrial fibrillation. Ventricular fibrillation. Asystole.

sinus tachycardia. Sinus tachycardia is distinguished by a heart rate greater than 100 beats per minute, a regular rhythm present, and P waves. >>>>>>>>>>>Atrial fibrillation.<<<<<<<<<<<< Atrial fibrillation commonly occurs in heart failure. Multiple areas in the atria initiate rapid, irregular electrical stimuli, which results in the inability to see clear P waves on the ECG recording. Some, but not all, of these electrical impulses travel through the AV node, causing an irregular ventricular response. This appears as irregular QRS complexes on the ECG recording and manifests as an irregular pulse rhythm when assessing the client. Ventricular fibrillation. Ventricular fibrillation is distinguished by totally chaotic electrical activity on the ECG recording, with no discernible P waves or QRS complexes (ventricular response). In addition, the client would not be arousable and would lack a pulse. This fatal dysrhythmia requires immediate defibrillation and CPR. Asystole. Asystole is distinguished by a flat line (no electrical activity of any kind) on the ECG recording. In addition, the client would not be arousable and would lack a pulse. This fatal dysrhythmia requires immediate CPR.