N136 Week 4 - Heart Failure with Atrial Fibrillation

Section 13 Therapeutic Communication: Nonverbal Cues While the client is in the Medical Intensive Care Unit (MICU), the nurse observes the daughter in the family waiting room. The daughter is sitting alone in a dark corner of the room with her arms folded across her chest. She is staring at the blank wall and does not answer the telephone that is ringing next to her. Question 27 of 30 The nurse's best response in this situation would be what? "I'm glad to see you are getting some rest." "Do you have someone to sit with you?" "Withdrawing will not help your father." "You are going through a very difficult time."

"I'm glad to see you are getting some rest." The nurse is making an assumption, which may or may not be accurate. "Do you have someone to sit with you?" This question is challenging and belittling, which is a block to further communication. "Withdrawing will not help your father." Giving advice is a block to further communication. "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. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 68.

Section 5 Medication Administration The HCP orders the following medications: Digoxin 0.125 mg IV every 6 hours x 4 doses, then 0.25 mg PO, daily. Furosemide 40 mg IV push daily. Captopril 12.5 mg PO three times a day. Docusate sodium 100 mg PO twice a day. Carvedilol 3.125 mg PO twice a day. Warfarin 5 mg PO daily. Question 6 of 30 Fill in the blankThe RN charge nurse prepares a dose of digoxin 0.125 mg IV push. The medication is supplied as 0.25 mg in 2 mL. How many mL should the RN prepare to give? (Enter numeric value only. If rounding is necessary, round to the whole number.)

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Section 10 Management Issues: Staffing Assignment The charge nurse is making client care assignments. Question 21 of 30 Which member of the nursing staff would be best assigned to the client while they are receiving treatment for his digoxin toxicity? A practical nurse (PN) from an agency pool who states that he has 5 years of med-surg experience. A PN who has worked on the Cardiac Observation Unit for the last 2 years. A new graduate registered nurse (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.

A practical nurse (PN) from an agency pool who states that he has 5 years of med-surg experience. This is not the best assignment, since the client requires skilled assessment and a high level of clinical judgment. A PN who has worked on the Cardiac Observation Unit for the last 2 years. This is not the best assignment, since the client requires skilled assessment and a high level of clinical judgment. A new graduate registered nurse (RN) who has just completed a 4-week orientation on the unit. This is not the best assignment, since the client requires skilled assessment and a high level of clinical judgment. An experienced critical care RN who has been assigned to "float" on the unit. This is the best assignment, since the client requires the assessment skills and clinical judgment abilities of an experienced RN. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 1238. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 233.

Question 4 of 30 After the client's cardiac rhythm is confirmed, which action should the nurse implement next? Administer an ordered stat dose of digoxin. Notify the HCP of the dysrhythmia. Transfer the client to the Medical Intensive Care Unit (MICU). Prepare for synchronized cardioversion.

Administer an ordered stat dose of digoxin. 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 the client's type of cardiac dysrhythmia. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 329. Notify the HCP of the dysrhythmia. This should be done if the nurse's first action does not slow the ventricular rate. The client's cardiac dysrhythmia would be considered controlled if the ventricular response (as reflected by the QRS complexes and pulse rate) is less than 100 beats per minute. Transfer the client to the Medical Intensive Care Unit (MICU). This will probably not be necessary, but it is a possibility. The client's cardiac dysrhythmia can result in seriously diminished cardiac output, but it can usually be controlled. It is not considered a life-threatening dysrhythmia. Prepare for synchronized cardioversion. This procedure would be used to convert a cardiac dysrhythmia to a normal sinus rhythm, but other options should be implemented first.

Section 9 Digoxin Toxicity The client returns to the clinic several weeks later and reports to the nurse that they are experiencing headaches and double vision. The client reports currently taking digoxin, furosemide, and 1 (one) aspirin each day. The client also report having 2 diarrhea stools that day. The client's pulse rate is 62 beats/min and irregular with frequent ectopic beats. Question 17 of 30 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 the client's headache. Instruct the client to withhold the next daily dose of aspirin.

Assess the consistency and amount of the diarrhea. This is an important intervention, but it is of less priority than other interventions. Obtain a serum potassium level. The client is exhibiting signs of digitalis toxicity and hypokalemia (low potassium). The nurse should immediately obtain significant laboratory values, including serum potassium and digoxin levels. Hypokalemia potentiates the effect of digoxin and can result in digoxin toxicity. Serum potassium levels should range between 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). If the potassium value is 3.0 or less, the nurse should withhold the dose of digoxin, and notify the healthcare provider. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 620. Obtain a prescription for an analgesic for the client's headache. Although administration of a PRN prescription to help alleviate the discomfort associated with the client's headache may be warranted, it is of less priority than other interventions. Instruct the client to withhold the next daily dose of aspirin. Aspirin is prescribed to reduce platelet aggregation, or clumping, which causes clot formation that increases the risk for stroke or heart attack. It is important to monitor the bleeding time of clients taking aspirin, but there is no reason to withhold aspirin at this time.

Section 8 Discharge Teaching The client is being discharged from the acute care setting to resume living at home. The client's daughter will check in frequently. Question 14 of 30 The client has been taking alpha-adrenergic blocker carvedilol 3.125 mg PO twice daily. Which interventions are important for the nurse to include in the client's discharge plan? (Select all that apply. One, some, or all options may be correct.) Select all that apply Avoid abrupt transitions to an erect posture. Expect 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 dose.

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). Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 240. Expect full antihypertensive effect noted in 4 weeks. It takes approximately 1 to 2 weeks for carvedilol to be effective. Take with food, and restrict salt and alcohol intake. Carvedilol works best if you take it with food. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 239. Do not quickly discontinue the medication. Stopping the medication suddenly may make the condition worse. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 239. 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. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 240.

The client is admitted to the Cardiac Observation Unit in the acute care facility for management of his digoxin toxicity. Digoxin toxicity is a common problem, occurring in up to 20% of all clients taking digitalis preparations. Digoxin has a narrow therapeutic index, meaning that there is a narrow range between the therapeutic dose and the toxic dose. All clients receiving digoxin should be monitored for digoxin toxicity. The nurse assesses the client for symptoms of digoxin toxicity. Question 19 of 30 Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity? Blood pressure 180/100. Anorexia, nausea, and vomiting. Pitting dependant ankle edema. Blurred vision and halo vision.

Blood pressure 180/100. Hypotension with resultant dizziness may be a symptom of digoxin toxicity. Anorexia, nausea, and vomiting. Gastrointestinal (GI) symptoms are among the earliest symptoms of digoxin toxicity, along with confusion and fatigue. Additional manifestations include headache, hypotension, and cardiac dysrhythmias. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 312. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 650. Pitting dependant ankle edema. Edema is not a manifestations of digoxin toxicity. Blurred vision and halo vision. Visual disturbances are common, but they are usually late symptoms of digoxin toxicity.

The client's initial admission orders include: Continuous cardiac monitoring. IV: 1,000 mL sodium chloride 0.9% with 40 mEq (40 mmol/L) KCI at 75 mL/hr. Digoxin immune FAB 38 mg IV. Digoxin immune FAB acts by binding with digoxin already in the bloodstream, resulting in removal of the digoxin and the prevention of further toxic effects. Question 20 of 30 After treatment with digoxin immune FAB, which of the client's serum laboratory values requires intervention by the nurse? Calcium 12 mg/dL (3.0 mmol/L). Potassium 3.2 mEq/L (3.2 mmol/L). Magnesium 1.94 mg/dL (0.80 mmol/L). Phosphorus 4.64 mg/dL (1.5 mmol/L).

Calcium 12 mg/dL (3.0 mmol/L). Calcium is not significantly affected by digoxin immune FAB . Potassium 3.2 mEq/L (3.2 mmol/L). A precipitous drop in serum potassium may occur after treatment with digoxin immune FAB . Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 400. Magnesium 1.94 mg/dL (0.80 mmol/L). Magnesium is not significantly affected by digoxin immune FAB . Phosphorus 4.64 mg/dL (1.5 mmol/L). Phosphate is not significantly affected by digoxin immune FAB .

Section 14 Discharge Teaching: Dietary Management of a Client with Heart Failure The client's condition steadily improves. Three days later, their condition stabilizes, and they are transferred back to the Cardiac Observation Unit, where the nurse begins discharge teaching. The nurse includes dietary management in the client's teaching plan. The prescribed diet is a 2 gram sodium diet. Since the client will be taking a high dose of furosemide, they also need instructions regarding foods high in potassium. Following the teaching session, the nurse evaluates what the client has learned by asking the client to select an appropriate menu. Question 29 of 30 Which menu selection by the client indicates that effective teaching has taken place? Canned tomato soup and a bologna sandwich on whole wheat bread. Fruit snacks to include bananas, oranges, dried apricots. Sliced ham, rice seasoned with salt substitute, and canned fruit cocktail. Veggie burger, french fries, cookies, and a diet soda.

Canned tomato soup and a bologna sandwich on whole wheat bread. Canned soups, whole wheat bread, and prepared luncheon meats, such as bologna, are high in sodium. Fruit snacks to include bananas, oranges, dried apricots. Since restricting potassium is not a concern for the client and there is a loss of potassium due to taking furosemide, snacks high in potassium are excellent choices. Nix, S. (2017). Williams' Basic Nutrition and Diet Therapy. (15thedition). St. Louis, Missouri. Elsevier. Pg. 341. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 332. Sliced ham, rice seasoned with salt substitute, and canned fruit cocktail. Pork products such as ham and canned products are generally high in sodium. Since restricting potassium is not a concern for the client, the use of a salt substitute (which is high in potassium) is a good choice. Veggie burger, french fries, cookies, and a diet soda. Dairy products, fried foods, and many baked goods are high in sodium.

Question 30 of 30 In an effort to monitor his heart failure, what is the most important intervention that the client can perform at home? Check radial pulse 6 times a day, upon arising, at each meal, and before bed. Take weekly ankle measurements to monitor edema. Weighing every day on the same scale. Incorporate a regular exercise routine.

Check radial pulse 6 times a day, upon arising, at each meal, and before bed. There is no indication that a client needs to perform frequent pulse checks. Take weekly ankle measurements to monitor edema. Meaurement of ankles is not necessary. Edema can be visually monitored. Weighing 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. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 332. Incorporate a regular exercise routine. Although regular exercise has positive benefits for breathing, it is not the most important.

Question 7 of 30 After administration of the prescribed captopril, which assessment finding warrants intervention by the nurse? Complaint of lightheadedness. Decrease in baseline blood pressure. Onset of dry and persistent cough A decrease in heart rate.

Complaint of lightheadedness. Lightheadedness is a common side effect and does not require immediate intervention. Decrease in baseline blood pressure. Captopril 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 the client's blood pressure to ensure that the medication is having the desired effect, and that hypotension does not occur. Excessive hypotension and hyperkalemia may occur. Monitor the client for first-dose hypotension (first-dose syncope). Willihnganz, M., Gurevitz, S., Clayton, B. (2020). Clayton's Basic Pharmacology for Nurses. (18thedition). St. Louis, Missouri. Elsevier. Pg. 353. Onset of dry and persistent cough A dry, persistant cough is a common side effect and does not require immediate intervention. A decrease in heart rate. A decrease in heart rate is a desired outcome.

Question 15 of 30 The client will be going home on carvedilol 12.5 mg PO twice daily. Choose the most important side effect for the nurse to include in the discharge teaching and document in the electronic medical record (EMR). Development of cough. Slow pulse rate. Dizziness upon standing. Onset of nausea.

Development of cough. Although this is an adverse effect of ACE inhibitors, it is not potentially life-threatening and therefore not the most important. Slow pulse rate. Overdose can produce profound bradycardia, hypotension, and bronchospasm, all of which can be life threatening. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 240. Dizziness upon standing. Dizziness may occur due to a temporary, sudden drop in blood pressure upon standing (orthostatic). Onset of nausea. Although this is an adverse effect of ACE inhibitors, it is not potentially life-threatening and therefore not the most important.

Question 8 of 30 The nurse is monitoring the client's serum electrolytes. Which of the client's serum laboratory values requires intervention by the nurse? Digoxin 2.0 ng/mL (2.56 nmol/L). Sodium 135 mEq/L (135 mmol/L). Potassium 3.0 mEq/L (3.0 mmol/L). Calcium 8.72 mg/dL (2.18 mmol/L).

Digoxin 2.0 ng/mL (2.56 nmol/L). Normal level of the Digoxin is between 0.5 and 2.0 ng/mL (0.64 - 2.56 nmol/L) Sodium 135 mEq/L (135 mmol/L). Normal blood sodium level is between 135-145 mEq/L (135 and 145 mmol/L). Potassium 3.0 mEq/L (3.0 mmol/L). Normal potassium is 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L). The diuretic (furosemide) decreases sodium reabsorption which enhances sodium and water loss putting the client at risk for hypokalemia. Even though 3.0 is not critically low, hypokalemia increases the risk for digoxin toxicity. Pagana, K., Pagana, T., Pagana T.N. (2019). Mosby's Diagnostic and Laboratory Test Reference. (14th edition). St Louis, Missouri. Elsevier. Pg. 724. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 311, 312. Calcium 8.72 mg/dL (2.18 mmol/L). Calcium narrow range is from 8.72 - 10.32 mg/dL (2.18 - 2.58 mmol/L).

Section 3 Cardiac Dysrhythmias Left-sided heart failure results in pulmonary fluid overload, and right-sided heart failure results in peripheral fluid overload. Left-sided heart failure usually occurs first, and can trigger right-sided heart failure. Upon admission to the Cardiac Nursing Unit, the client's dyspnea continues. The client reports fatigue, but denies chest pain. The nurse places the client on oxygen via a nasal cannula at 3 L/min and a cardiac telemetry monitor. The ECG recording shows no discernible P waves, and a rapid, irregular ventricular response (QRS complexes). This corresponds with the client's pulse rate, which is 136 and irregular. Question 3 of 30 Based on the electrocardiogram rhythm strip, what intervention should the nurse implement first? Ensure the client has two large bore IV sites. Obtain a 12 lead ECG. Gather supplies to obtain venous blood to be sent to the laboratory. Prepare the client for elective cardioversion.

Ensure the client has two large bore IV sites. IV sites will be needed for medication to be given as prescribed to slow down or convert the rhythm to a sinus rhythm. A second site is recommended in the event the rhythm deteriorates to a more lethal rhythm such as ventricular fibrillation. Obtain a 12 lead ECG. A 12 lead should be performed immediately to confirm the rhythm and determine if there is any acute myocardial injury occuring. 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. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 301, 310, 326. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 683. Gather supplies to obtain venous blood to be sent to the laboratory. The healthcare provider (HCP) will instruct the nurse to draw blood to be evaluated for electrolytes, coagulation studies, and cardiac specific laboratory values. Prepare the client for elective cardioversion. Cardioversion may be indicated to attempt to shock the heart back into a regular rhythm but is not priority unless the patient is unstable.

Question 18 of 30 Which of the client's serum laboratory values requires intervention by the nurse? Hemoglobin 129 g/L (129 g/L). White blood cells 12000 /mcL (12 x 109 /L). Calcium 16 mg/dL (4 mmol/L). Albumin 3 g/dL (30 g/L).

Hemoglobin 129 g/L (129 g/L). Anemia (decreased hemoglobin) will not place the client at greatest risk for digoxin toxicity. White blood cells 12000 /mcL (12 x 109 /L). Leukocytosis (elevated WBCs) will not place the client at greatest risk for digoxin toxicity. Calcium 16 mg/dL (4 mmol/L). Calcium binds with digitalis to decrease the effects of digoxin. 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. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 614. Pagana, K., Pagana, T., Pagana T.N. (2019). Mosby's Diagnostic and Laboratory Test Reference. (14th edition). St Louis, Missouri. Elsevier. Pg. 189. Albumin 3 g/dL (30 g/L). Hypoalbuminemia will not place the client at greatest risk for digoxin toxicity.

Section 1 Question 1 of 30 Knowing that the client has two risk factors that cannot be modified, which intervention is most important for the nurse to include in the client's plan of care? Identify any family history of lung disease. Complete a focused cardiac history assessment. Evaluate the client's lower extremities for varicosities. Review history for episodes of hypotension. Risk Factors Heart failure results in the inability of the heart to provide sufficient blood flow to meet the oxygen needs of the body's tissues and organs. Heart failure occurs most commonly in clients over the age of 60, and occurs more commonly in males than females.

Identify any family history of lung disease. Lung disorders, such as asthma and chronic bronchitis, are not commonly associated with an increased risk for heart failure. However, they can precipitate heart failure. Complete a focused cardiac history assessment. 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 the client if they have hypertension which is another primary underlying condition causing heart failure. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 326, 329, 330. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 320. Evaluate the client's lower extremities for varicosities. Varicose veins are not associated with an increased risk for heart failure. Review history for episodes of hypotension. Systemic hypertension increases the work of the heart and is one of the primary underlying conditions causing heart failure. However, hypotension is not considered a contributory risk factor for heart failure.

Upon obtaining the oxygen saturation level, the nurse notes that the reading is below 80. The HCP is contacted immediately and requests the nurse perform a stat arterial blood gas. The results are returned to the nurse and the reading is pH 7.24, PaCO2 60mmHg, HCO3 27 mEq/L (27 mmol/L), and PaO2 52 mmHg. Question 23 of 30 How would this reading be interpreted by the nurse? Mild hypoxemia. Metabolic acidosis. Severe hypoxemia. Respiratory acidosis.

Mild hypoxemia. Mild hypoxemia is defined as PaO2 between 60-79 mmHg and oxygen saturation betwwen 88-90%. Metabolic acidosis. Metabolic acidosis is diagnosed when the HCO3 is low and the pH is low. Severe hypoxemia. Severe hypoxemia is defined as PaO2 less than 40 mmHg and oxygen saturation less than 75%. Respiratory acidosis. Respiratory acidosis is diagnosed with the PaCO2 is high and the pH is low. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 377.

Question 9 of 30 The client is concerned about how easily they are bruising since they started taking the warfarin. Which intervention is most important for the nurse to include in the client's plan of care? Monitor INR levels every 4-6 weeks. Use soft toothbrush to minimize bleeding gums. Use electric razors for shaving. Avoid contact sports and hobbies.

Monitor INR levels every 4-6 weeks. The target INR for warfarin is 2.4 - 3.5. INR should be monitored on a regular basis. Changes in the warfarin dosage will be adjusted to keep the INR within a safe range which will decrease the risk of a life-threatening bleed. Pagana, K., Pagana, T., Pagana T.N. (2019). Mosby's Diagnostic and Laboratory Test Reference. (14th edition). St Louis, Missouri. Elsevier. Pg. 754, 755. Willihnganz, M., Gurevitz, S., Clayton, B. (2020). Clayton's Basic Pharmacology for Nurses. (18thedition). St. Louis, Missouri. Elsevier. Pg. 524. Use soft toothbrush to minimize bleeding gums. Minor bleeding is an expected side effect for anticoagulants. Intervention is warranted if bleeding becomes excessive or continuous. Use electric razors for shaving. Using an electric razor will minimize the risk of cuts that may happen with traditional razors. Avoid contact sports and hobbies. Aggressive sports or hobbies may cause increased brusing and possible internal bleeding.

Question 13 of 30 Select additional instruction(s) the nurse should include in the client's teaching plan. (Select all that apply. One, some, or all options may be correct.) Select all that apply Monitor pulse prior to administration of digoxin. Immediately report a cold or sore throat to your healthcare provider. If a dose of digoxin 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.

Monitor pulse prior to administration of digoxin. It is necessary to monitor pulse while receiving digoxin. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 332. Immediately report a cold or sore throat to your healthcare provider. Digoxin does not cause increased susceptibility to infections, so a cold or sore throat is not related to the digoxin. If a dose of digoxin is missed, double the next dose. A double dose may be excessive and lead to toxicity. The client may be instructed to take a missed dose within several hours, but the prescribed dose should not be doubled. 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 and lethal arrhythmias. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 332. Regular blood draws will be necessary to measure prothrombin time (PT) and INR. The client is taking warfarin. PT and INR must be monitored regularly to ensure accurate dosing and prevent complications such as bleeding or clotting. Willihnganz, M., Gurevitz, S., Clayton, B. (2020). Clayton's Basic Pharmacology for Nurses. (18thedition). St. Louis, Missouri. Elsevier. Pg. 524.

Question 26 of 30 The best nursing action in response to this decision would be to? Notify the HCP of the daughter's wishes. Notify the hospital supervisor of the daughter's wishes. Write a "DNR per family wishes" order. Place an arm band on the client that reflects the code status.

Notify the HCP of the daughter's wishes. Do not resuscitate (DNR) orders must be written by the HCP to be legally binding. Potter, P., Perry, A., Stockert, P., Hall, A. (2019). Essentials for Nursing Practice. (9th edition). St. Louis, Missouri. Elsevier. Pg. 67. Notify the hospital supervisor of the daughter's wishes. The hospital supervisor is not generally involved in direct care or decision-making. Write a "DNR per family wishes" order. Nurses may not write DNR orders. Place an arm band on the client that reflects the code status. Once the DNR is signed in the medical record, there needs to be a way to easily identify the DNR status.

Section 7 Nursing Interventions The nurse enters the client's room and finds the client lying supine in bed with a respiratory rate of 32 breaths/minute and reporting back pain. Interventions implemented by the nurse include: Monitoring the ECG, vital signs, degree of peripheral edema, and daily weights Monitor and record oral and IV fluid intake Review laboratory results and therapeutic range Implementation of fall precautions The client responds well to the plan of care. The nurse initiates client teaching regarding medication management, in anticipation of discharge. Question 12 of 30 What is the first action that the nurse should implement when entering the client's room? Notify the respiratory therapist. Assist the client to turn on his side. Elevate the head of the client's bed. Offer the client a back massage.

Notify the respiratory therapist. This may be necessary if other measures are not sufficient to improve the client's dyspnea. Assist the client to turn on his side. This is an important measure to relieve the client's discomfort, and it can be implemented after other measures are taken to relieve the client's dyspnea. Elevate the head of the client's bed. Since the nurse knows that the client 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 the client 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. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 332. Offer the client a back massage. This is an important measure to relieve client's discomfort, and it can be implemented after measures are taken to relieve his dyspnea.

Section 11 A Complication Occurs During the client's treatment with digoxin Immune FAB, the nurse's focused assessment notes increasing confusion, restlessness, and development of a frothy productive cough. The client's vital signs are: temperature 98.6° F (37.0° C) , heart rate 148 beats/minute, respirations 36 breaths/minute, and blood pressure 120/80 mm/Hg. Question 22 of 30 While applying supplemental oxygen, which intervention is priority for the nurse to initiate? Position patient upright unless contraindicated and give O2 by nasal cannula or non-rebreather mask. Obtain baseline vital signs, including O2 saturation. Auscultate heart for regularity and breath sounds for crackles. Initiate suctioning to remove lung secretions.

Position patient upright unless contraindicated and give O2 by nasal cannula or non-rebreather mask. The first priority is to ensure adequate oxygenation. Client is exhibiting symptoms of pulmonary edema, which results in compromised oxygenation, requiring immediate action by the nurse. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 332. Obtain baseline vital signs, including O2 saturation. Based on the client's symptoms, there may be a need for further intervention based on these findings. Auscultate heart for regularity and breath sounds for crackles. Based on the client's symptoms, there may be a need for further intervention based on these findings. Initiate suctioning to remove lung secretions. Since the client is clearing his airway by coughing, suctioning is not yet necessary.

Section 2 Clinical Manifestations Right-sided, or right ventricular, heart failure often occurs due to left-sided heart failure when the weakened or stiff left ventricle cannot efficiently pump blood to the rest of the body. As a result, fluid is forced back through the lungs, weakening the heart's right side, causing right-sided heart failure. Question 2 of 30 Which assessment finding provides the earliest indication that the client is experiencing right-sided heart failure? Dyspnea at rest. Sinus tachycardia. Peripheral edema. Lack of energy.

Question 2 of 30 Which assessment finding provides the earliest indication that the client is experiencing right-sided heart failure? Dyspnea at rest. Dyspnea and lung crackles are manifestations of left-sided heart failure. Left-sided heart failure results in pulmonary congestion, due to the inability of the left ventricle to pump blood out of the heart and into the systemic circulation effectively. Sinus tachycardia. Tachycardia is a manifestation of left-sided heart failure as the heart attempts to compensate for diminishing cardiac output. Peripheral 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. Edema and weight gain are among the earlier signs. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 327, 329. Lack of energy. Fatigue (lack of energy) and anxiety are manifestations of left-sided heart failure. As the tissues receive less oxygen to meet oxygenation needs, the client struggles to obtain adequate air.

Section 4 Diagnostic Studies The client is scheduled for a chest x-ray, 12 lead electrocardiograph (ECG) and an echocardiogram. Question 5 of 30 When preparing the client for the echocardiogram, which intervention should the nurse implement? Set-up treadmill for initial test. Instruct the client to fast for at least 6 hours before the test. Ensure the client is wearing comfortable clothes and shoes. Ask the client to lay supine during the test.

Set-up treadmill for initial test. Treadmill is not needed for a basic echocardiogram. Only if the test is prescribed as a Stress Echocardiogram. Instruct the client to fast for at least 6 hours before the test. Fasting is not necessary unless prescribed a transesophageal echocardiogram (TEE). Ensure the client is wearing comfortable clothes and shoes. Clothing does not matter unless the patient is prescribed an exercise stress echocardiogram test. Ask the client to lay supine during the test. The echocardiogram records direction and flow of blood through the heart and transforms it to audio and graphic data that measure valve abnormalities, congenital heart defects, wall motion, ejection fraction (EF), and heart function. The best results are obtained when the patient is in the supine position. The technician may also request the client to lay on their left side. Pagana, K., Pagana, T., Pagana T.N. (2019). Mosby's Diagnostic and Laboratory Test Reference. (14th edition). St Louis, Missouri. Elsevier. Pg. 339, 340.

Question 25 of 30 If the client had not provided an advance directive, who should be consulted next, with regard to helping the daughter make the best decision regarding the client's care? (Select all that apply. One, some, or all options may be correct.) Select all that apply Social worker. Clergy person. Healthcare providers. The client's extended family. Hospital administrators.

Social worker. The social worker is an integral part of the team, and should be consulted regarding end-of-life decisions. Williams, P. (2018). Fundamental Concepts and Skills for Nursing. (5thedition). St. Louis, Missouri. Elsevier. Pg. 32. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 325. Clergy person. The clergy person is an integral part of the team, and should be consulted regarding end-of-life decisions. Williams, P. (2018). Fundamental Concepts and Skills for Nursing. (5thedition). St. Louis, Missouri. Elsevier. Pg. 32. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 325. Healthcare providers. The healthcare providers are an integral part of the team, and should be consulted regarding end-of-life decisions. Williams, P. (2018). Fundamental Concepts and Skills for Nursing. (5thedition). St. Louis, Missouri. Elsevier. Pg. 32. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 325. The client's extended family. Family that know the client may be supportive and help his daughter make an informed decision. Williams, P. (2018). Fundamental Concepts and Skills for Nursing. (5thedition). St. Louis, Missouri. Elsevier. Pg. 32. Linton, A., Matteson, M. (2020). Medical-Surgical Nursing. (7th edition). St. Louis, Missouri. Elsevier. Pg. 325. Hospital administrators. While hospital administrators are potentially available for consultation regarding end-of-life decision-making, they are not considered a primary resource.

Question 28 of 30 Choose the best nursing action to implement in response to the daughter's behavior. Stay seated next to the daughter and remain quietly attentive. Turn on the television to provide the daughter with a distraction. Provide the daughter with palliative care pamphlets . Leave the waiting room quietly to show respect for the daughter and to provide her privacy.

Stay seated next to the daughter and remain quietly attentive. Silence and offering one's presence are effective therapeutic techniques to encourage communication. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 68. Turn on the television to provide the daughter with a distraction. This action will limit the possibility for further communication. Provide the daughter with palliative care pamphlets . Palliative care is more for end-of-life comfort care. Leave the waiting room quietly to show respect for the daughter and to provide her privacy. This action will eliminate any possible further communication.

Section 12 Ethical-Legal Issues: Decisions about Resuscitation The client is exhibiting symptoms consistent with pulmonary edema. This life-threatening complication of heart failure is the result of increasing pressure in the left ventricle causing fluid leakage across the pulmonary capillary membranes. Additional manifestations of pulmonary edema include crackles in the lung bases, frothy, blood-tinged sputum, cyanosis, cold, clammy skin, anxiety, and severe dyspnea. The priority nursing problem is "altered gas exchange." The client is placed on oxygen via nasal cannula at 5 L/min, and is transferred to the Medical Intensive Care Unit (MICU), where IV diuresis is initiated. The client's condition is critical, they are disoriented and difficult to arouse. The nurse explains to the client's daughter that the oxygenation level is decreasing, and the client may soon require endotracheal intubation and mechanical ventilation. The daughter expresses that she is not sure what to do because she feels that this is not the kind of treatment the client would want. Question 24 of 30 The client's daughter and the nurse should utilize which source during this decision-making process? The nursing code of ethics. The hospital's risk management team. The client's documented wishes for life-saving measures. The client's case manager.

The nursing code of ethics. Follow a code of ethics for all clinical actions, but these general guidelines will not be useful as a resource for the daughter's decision. The hospital's risk management team. The role of a risk management team is to evaluate matters related to legal decisions and are not needed in this decision-making process. The client's documented wishes for life-saving measures. 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 the daughter and the nurse to determine the course of action that the client would want if they were able to make a decision at this time. Williams, P. (2018). Fundamental Concepts and Skills for Nursing. (5thedition). St. Louis, Missouri. Elsevier. Pg. 39. The client's case manager. A case manager is a nurse or social worker that focuses on the management of a client's care during a spectrum of care. The case manager will be useful to the nurse and to the daughter, but another choice is a more direct resource.

Question 16 of 30 The client is now on furosemide 20 mg PO twice daily. The client is aware that this medication increases urinary output. Which interventions should be included in the client's discharge teaching? (Select all that apply. One, some, or all options may be correct.) Select all that apply Wear sunblock and long sleeves when out in the sun. Measure daily urine output. Expect anorexia and nausea. Swollen skin remains indented after being pressed. Report dry mouth and excessive thirst.

Wear sunblock and long sleeves when out in the sun. Furosemide is photosensitive. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 592. Measure daily urine output. It is not necessary to measure urine. Decrease in edema and ease of breathing are good indicators that the medication is working. Expect anorexia and nausea. Anorexia and nausea are see more with thiazide diurectis. Swollen skin remains indented after being pressed. Pitting edema is a sign of fluid retention. Therefore the diuretic dosage may need to be increased. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 592. Report dry mouth and excessive thirst. Excessive thirst may be an indication of dehydration, requiring a decrease in the medication. Skidmore-Roth, L. (2021). Mosby's 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 592.

Question 11 of 30 The client asks the nurse why they have to be weighed every day. The nurse explains that weight gain is one of the first signs of retaining fluid. Which intervention is most important for the nurse to include in the client's plan of care? Weigh at the same time of day. Keep a record of daily weights. Report a gain of 3 pounds in one week. Inform healthcare provider of ankle swelling.

Weigh at the same time of day. Weight is most accurate if done at the same time of day with the same amount of clothes on. Keep a record of daily weights. A record of weights shows gradual weight changes and should be taken to any follow-up appointments. Report a gain of 3 pounds in one week. A weight gain of 3 pounds in 2 days or 3-5 pounds in a week should be reported immediately. This may indicate an exacerbation of the heart failure which requires immediate intervention. Cooper, K., Gosnell, K. (2019). Adult Health Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 332, 437. Inform healthcare provider of ankle swelling. Ankle swelling is a sign of fluid retention but it is not as measurable as weight gain.

Section 6 Diet Teaching and Weight Management Diet teaching and weight management are essential. The nurse interviews the client and obtains a detailed diet history. Question 10 of 30 The nurse observed a family member bringing the client food from home. Which intervention is most important for the nurse implement? Write low sodium diet on the white board in the client's room. Record the meal in the electronic medical record. Instruct the family to inform the nurse when bringing in food. Teach the client and his family what foods are low in sodium.

Write low sodium diet on the white board in the client's room. Writing the diet on the white board will only help if the client and family are aware of what that means. Record the meal in the electronic medical record. Recording dietary intake is an essential part of the medical record but it is not priority of education in this instance. Instruct the family to inform the nurse when bringing in food. The nursing staff should be aware of the food the client eats but more importantly, intercept food that is not low in sodium. Educating the client and family will correct this behavior. Teach the client and his family what foods are low in sodium. Poor adherence to a low-sodium diet is one of the main reasons clients are readmitted to the hospital. Teaching and providing diet options are priority. Nix, S. (2017). Williams' Basic Nutrition and Diet Therapy. (15thedition). St. Louis, Missouri. Elsevier. Pg. 335, 336.