Chapter 44 PrepU

The nurse is providing education to a client who has been prescribed digoxin for symptomatic heart failure. What teaching point would the nurse convey to this client?

"Make sure to take your pulse for a minute before taking your digoxin." Clients should measure their heart rate for a full minute before taking a dose of digoxin. The drug can be taken with food, and potassium intake should be increased, not decreased. The client's daily dose of digoxin should never be increased in response to short-term changes in symptoms.

A male client who is prescribed digoxin asks the nurse how he should take the drug. Which instruction would be most appropriate?

"Take the drug on an empty stomach at the same time each day." Food and antacids interfere with the absorption of the drug. Digoxin should be taken on an empty stomach at approximately the same time each day. If the client takes an antacid, the client should separate the dose of antacid and digoxin by 2 to 4 hours.

A patient is receiving milrinone IV. The nurse would administer the bolus over which time frame?

10 minutes Milrinone is administered by IV bolus over 10 minutes.

A nurse obtains the serum digoxin level and immediately reports a level greater than which value?

2.0 ng/mL. A nurse must immediately report serum digoxin levels greater than 2.0 ng/mL. Therapeutic drug levels are between 0.8 and 2 ng/mL.

A client experiences nausea and visual disturbances when taking digoxin (Lanoxin). The nurse would anticipate the client's digitalis level to be:

2.7 nanograms/mL Therapeutic drug levels of digoxin are between 0.8 and 2 nanograms/ mL. Plasma digoxin levels greater than 2 nanograms/mL are considered toxic and the client may experience signs and symptoms of toxicity.

A nurse is administering digoxin intravenously as ordered. The nurse would administer the drug over which time frame?

5 minutes Intravenous digoxin must be administered slowly over at least 5 minutes to prevent cardiac arrhythmias and adverse effects.

When caring for a patient who has been digitalized for his heart failure, the nurse observes that the patient is experiencing bradycardia. Which drug should be administered to patients who develop bradycardia?

Atropine Atropine should be administered to patients who develop bradycardia. Bradycardia may be seen in digitalis toxicity. Inamrinone and milrinone are miscellaneous inotropics used in heart failure. Cholestyramine is used to lower blood cholesterol levels. Inamrinone, milrinone, and cholestyramine are not used in the treatment of bradycardia.

After teaching a group of students about cardiomyopathy as a cause of heart failure, the instructor determines the need for additional teaching when the students identify what as a cause of cardiomyopathy?

Bacterial infection Cardiomyopathy is a result of a viral infection, alcoholism, anabolic steroid use, or a collagen disorder.

A client is prescribed sacubitril and valsartan for treatment of heart failure. What laboratory blood values should the nurse monitor to assure the treatment is successful? Select all that apply.

Blood urea nitrogen Creatinine Potassium The nurse should assess for signs of improvement or stabilization of chronic heart failure by monitoring laboratory values to assure that blood urea nitrogen, creatinine, and potassium are within acceptable limits. It is not necessary to assess the other values to determine the success of treatment.

A patient is prescribed a cardiotonic medication. Which pre-administration assessment should the nurse perform on this patient?

Check for jugular vein distention. The nurse should check for jugular vein distention as part of the pre-administration assessment for the patient prescribed a cardiotonic. The nurse need not inspect joints for swelling, inspect skin for rash, or obtain blood glucose levels as these interventions will not provide necessary information with regard to administration of a cardiotonic.

When describing how vasodilators help alleviate heart failure, which would the nurse include?

Decrease afterload Vasodilators decrease cardiac workload, relax vascular smooth muscle to decrease afterload, and allow pooling in the veins thereby decreasing preload. Decreased blood volume results from the use of diuretics.

A nurse is planning an in-service program for a group of staff nurses about heart failure and its treatment. The nurse would identify which agent as the most commonly used drug for treatment?

Digoxin Digoxin is the drug most often used to treat heart failure. Human B-type natriuretic peptide, ACE inhibitors, or hydrochlorothiazide also may be used, but these drugs are not the most common ones used.

A 58-year-old man is admitted to the emergency department. A diagnosis of severe digoxin toxicity is made. Bradycardia is present, and an electrocardiogram (ECG) confirms toxicity. The nurse will administer which drug?

Digoxin immune fab Digoxin immune fab is used as the antidote to digoxin toxicity. The other drugs would not be used to treat digoxin toxicity. The patient could be taking furosemide as part of the drug regimen for heart failure.

The nurse is teaching a female patient about newly prescribed digoxin. The patient tells the nurse that she occasionally uses herbal therapies. The nurse should caution the patient against using therapies that involve which herbs

Ginseng Patients taking digoxin should avoid licorice, ginseng, or hawthorn because concomitant use of those products can increase drug effects or cause toxicity. In general, patients taking any medication should discuss all herbal remedies with a health care provider to assess for potential interactions.

A 65-year-old client presents to the health care provider's office with reports of shortness of breath on exertion, edema in the ankles, and waking up in the middle of the night unable to breathe. The nurse suspects that the symptoms are indicative of which condition?

Heart failure Cardinal manifestations of HF are dyspnea and fatigue, which can lead to exercise intolerance and fluid retention resulting in pulmonary congestion and peripheral edema.

A client is admitted to the intensive care unit with an electrolyte imbalance. Which imbalance will contraindicate the administration of digoxin?

Hypokalemia Digoxin is contraindicated in clients with hypokalemia. Digoxin is not contraindicated in clients with hyperkalemia, hypermagnesemia, or hypocalcemia because its effect would not increase the risk of arrhythmias.

The pharmacology instructor is discussing cardiac glycosides with a class of pre-nursing students. According to the instructor, what physiologic effect do cardiac glycosides trigger?

Increased force of heart contraction Cardiac glycosides increase the force of cardiac contraction, which increases cardiac output.

A nursing instructor is teaching a group of students about cardiotonics. The instructor determines the session is successful when the students correctly identify which as an action(s) of the cardiotonics? Select all that apply.

Increases myocardial efficiency Improves myocardial contractility Improves profusion to all body tissues Cardiotonics are drugs used to increase the efficiency and improve the contraction of the heart muscle, which leads to improved blood flow to all tissues of the body. An increased blood pressure and peripheral edema may be contributing causes for the need of cardiotonics.

A nurse has poured a hospital client's scheduled dose of hydrochlorothiazide (HCTZ). The nurse should know that this drug reduces preload by which means?

Increasing renal excretion of sodium and water Hydrochlorothiazide inhibits the reabsorption of sodium and chloride in the distal renal tubule, increasing the excretion of sodium and water by the kidneys. Thiazide diuretics do not relax smooth muscle, increase contractility, or stimulate the SA node.

A nurse is preparing to administer inamrinone. The nurse would administer this drug most likely by which route?

Intravenous Inamrinone is administered only by the intravenous route.

Milrinone is a miscellaneous inotropic drug used in the short-term management of heart failure. What is the only way this drug is approved to be administered?

Intravenously Milrinone is only to be given intravenously. The other routes are not used.

The nurse is preparing to administer digoxin to a 9-month-old infant. What must the nurse do prior to administration of this medication?

Monitor the infant's apical pulse The nurse must assess the client's apical pulse before administering digoxin because it has a narrow therapeutic index and can cause the heart rate to go too low, so the nurse takes the apical pulse and holds the medication if it is below a certain level (depending upon age of the client.)

The nurse is to administer digoxin to a client with heart failure. The nurse auscultates an apical pulse rate of 52. What action should the nurse take?

Notify the health care provider Before administering each dose of digoxin, take the apical pulse rate for 60 seconds. If the apical rate is below 60 beats per minute, withhold the drug and notify the provider. Blood pressure is not affected by digoxin. Without prescriptive authority, the nurse cannot change medication dosages.

A nurse is caring for a 66-year-old female client who is receiving digoxin. When preparing to administer a dose, the nurse observes that the client's apical pulse rate is 55 bpm. What is the appropriate action to take?

Omit the dose and contact the health care provider. Bradycardia is a potential adverse effect of digoxin. Nurses should assess the client's apical pulse before each dose. If the rate is lower than 60 bpm in an adult client, the nurse should omit the dose and notify the provider.

A client has been admitted to a health care center with reports of dyspnea. The nurse suspects left-sided heart failure based on which assessment finding?

Orthopnea The nurse should assess for orthopnea in clients with left-sided heart failure. Orthopnea is a condition where the client has difficulty breathing when lying down. The other features of left ventricular failure include a hacking cough or wheezing, restlessness, and anxiety. Nocturia, pitting edema, and weight gain are associated with right-sided heart failure.

The pharmacology instructor is describing medications that increase the contractile force of the heart. Which term describes this effect?

Positive inotropic A positive inotropic effect improves the contractility and pumping ability of the heart.

A nurse is caring for a client who is taking digoxin and a loop diuretic. Which would be most important for the nurse to monitor?

Potassium levels Although it is important to monitor the client's ECG, it is more important to closely monitor potassium levels when the client is taking a drug that promotes the loss of potassium, such as thiazide or loop diuretics. Hypokalemia increases the effect of digoxin and increases the risk for digoxin toxicity. The client's sodium levels and liver enzyme levels may need to be monitored periodically, but not as closely as potassium levels.

Which condition would least likely contribute to the development of heart failure?

Renal failure Renal failure would be least likely to contribute to the development of heart failure. Coronary artery disease, valvular disease, hypertension, and cardiomyopathy are commonly associated with heart failure.

A client asks the nurse about how prescribed digoxin helps the heart. The nurse would include which response? Select all that apply.

Slows the conduction velocity through the atrioventricular (AV) node Decreases heart rate Increases force of contraction Digoxin exerts the following effects on the heart: increases cardiac output via increased force of contraction, slows the conduction velocity through the AV node, and decreases heart rate.

Mrs. Houston is a 78-year-old woman who resides in an assisted living facility. Her provider prescribed digoxin at her last visit to the clinic and she has approached the nurse about this new drug. What teaching point should the nurse emphasize to Mrs. Houston?

The importance of having required laboratory work performed on time Clients taking digoxin need to know the importance of having all laboratory work (serum drug levels; electrolytes) performed on time. Digoxin is not taken if the client is bradycardic, and it does not provide an immediate or short-term increase in exercise tolerance. Blood pressure monitoring is not normally required for clients who are taking digoxin.

A triage nurse in the emergency department suspects that a 78-year-old patient is experiencing severe digoxin toxicity with significant cardiac arrhythmia. If the nurse is correct, which action is likely to be taken?

The patient will be given digoxin immune fab. Digoxin is stopped, not merely reduced, in patients experiencing toxicity. If digoxin toxicity is accompanied by serious arrhythmias, several drugs may be used, including potassium chloride (if serum potassium is low) and digoxin immune fab (if toxicity is serious).

A nurse assessing a client on digoxin suspects toxicity. Which visual disturbances would the nurse expect to assess?

Yellow or green vision The visual disturbance the nurse should assess for is yellow or green vision with a white halo. Visual disturbances occur in digoxin toxicity. Blurring of vision and borders around dark objects are the other visual disturbances. Double vision, difficulty of near vision, and complete loss of vision do not occur in digitalis toxicity.

A patient with class-IV CHF has a medication regimen consisting of metoprolol (Lopressor), enalapril (Vasotec), and furosemide (Lasix). In addition to regularly assessing the patient's heart rate, the nurse should prioritize assessment of the patient's

blood pressure Fluid balance, cognition, and exercise tolerance are all affected by CHF and should be regularly assessed as part of thorough nursing care. However, the combination of an ACE inhibitor, a beta blocker, and a diuretic constitutes a significant risk for hypotension and indicates a need for frequent blood pressure monitoring.

Calcium has inactivated a client's troponin, allowing actin and myosin to form a bridge. What effect will the nurse monitor for in this client?

cardiac muscle fibers to contract Calcium must be present to deactivate troponin so that actin and myosin can react to form actinomycin bridges. This results in muscle contraction, which would be associated with systole more than diastole. This phenomenon, occurring in many muscle fibers, would result in increased cardiac output. During repolarization, calcium leaves the cell, allowing troponin to prevent interaction between actin and myosin. This results in the relaxation of the fiber. This is a normal physiological process, not a pathological process that would cause an MI.

The nurse administers sacubitril to a client. The nurse will expect which action to occur?

decrease blood volume Neprilysin is the enzyme that breaks down natriuretic peptides in the body. These peptides are responsible for loss of sodium and resultant water in response to ventricular overload. By blocking their breakdown, their effects last longer and more sodium and water are lost. This effect in combination with blocking the angiotensin II receptors, which inhibits the effects of the RAAS, leads to decreased cardiac workload, lower vascular volume, lower blood pressure, and improved HF symptoms. Cardiac glycosides increase force of contraction

A client being treated for hypokalemia has a medication history that includes propranolol, digoxin, and warfarin. When the client reports nausea, abdominal discomfort, and visual changes, the nurse suspects what as the causative factor?

digitalis toxicity People diagnosed with hypokalemia can develop digitalis toxicity even when digoxin levels are not considered elevated. Signs of toxicity include potentially life-threatening heart rhythm disturbances, ranging from very slow to rapid ventricular rhythms. Other side effects include nausea, vomiting, loss of appetite, abdominal discomfort, blurred vision, and mental changes. The client's level is unlikely to be considered therapeutic or untherapeutic or to have resulted from an appropriate loading dose.

Which would the nurse identify as a cardiac glycoside?

digoxin Digoxin is a cardiac glycoside. Inamrinone and milrinone are phosphodiesterase inhibitors. Captopril is an angiotensin-converting enzyme inhibitor.

A client is experiencing nausea and visual disturbances when taking digoxin. Which medication will be administered?

digoxin immune fab Digoxin immune fab is a digoxin-binding antidote recommended only for severe digitalis poisoning with life-threatening symptoms. Acetylsalicylic acid is used to reduce fever and relieve mild to moderate pain. Nesiritide acts to compensate for deteriorating cardiac function by reducing cardiac preload and afterload. Felbamate is administered for the treatment of seizures. None of these medications are prescribed for digoxin toxicity.

The nursing instructor explains to students that positive inotropic action affects the heart in which way?

increased myocardial contraction Positive inotropic activity occurs with an increase in the force of the contraction. Conduction is slowed through the heart and there is a decrease, not an increase, in the heart rate.

A client presents to the ED with wheezing and blood-tinged sputum. The nurse suspects the client is experiencing pulmonary edema. The nurse should suspect the cause of the pulmonary edema is most likely:

left ventricular failure Pulmonary edema occurs when left ventricular failure (or dysfunction) results in accumulation of blood and fluid in pulmonary veins and tissues.

After teaching a group of students about conditions that can lead to heart failure, the instructor determines that additional teaching is needed when the students identify

renal failure Renal failure would be least likely to contribute to the development of heart failure. Coronary artery disease, cardiomyopathy, valvular disease, and hypertension are commonly associated with heart failure.