Chapter 44: Agents for Treating Heart Failure
A nurse obtains the serum digoxin level and immediately reports a level greater than which value? 0.1 ng/mL. 2.0 ng/mL. 1.0 ng/mL. 0.5 ng/mL.
2.0 ng/mL. Explanation: 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 patient is being administered digoxin (Lanoxin) for treatment of heart failure. At what level should the serum potassium level be maintained? 8.5-10 mEq/L 3.5-5.0 mEq/L 1.5-2.0 mEq/L 6.0-8.0 mEq/L
3.5-5.0 mEq/L Explanation: Electrolyte imbalance must be monitored during digoxin therapy, and the potassium level should be maintained at 3.5-5.0 mEq/L. A potassium level of 1.5-2.0 mEq/L is too low. Potassium levels of 6.0-80 and 8.5-10 mEq/L are too high.
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? "If the swelling in your feet gets worse, you can take up twice your normal dose for 1 day." "Make sure to take your pulse for a minute before taking your digoxin." "Plan to take your digoxin on an empty stomach to make sure it's fully absorbed." "Try to limit the number of high-potassium foods in your diet."
"Make sure to take your pulse for a minute before taking your digoxin." Explanation: 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 70-year-old woman has experienced peripheral edema and decreasing stamina in recent months and has sought care from her primary care provider. The patient's subsequent diagnostic workup has resulted in a diagnosis of chronic heart failure. The woman has been prescribed digoxin and the nurse has begun patient education. What should the nurse teach the patient about her new medication? "This will lessen the workload of your heart by reducing your blood pressure." "By reducing the amount of fluid that your body contains, digoxin will make it easier for your heart to pump." "Most patients see their heart failure resolve in 2 to 4 months after they begin taking digoxin." "This drug won't cure your disease, but it will help you be able to exercise more and be more comfortable."
"This drug won't cure your disease, but it will help you be able to exercise more and be more comfortable." Explanation: Digoxin is used to maintain clinical stability and improve symptoms, quality of life, and exercise tolerance in patients with all phases of CHF; it does not decrease mortality from CHF or cure the disease. Digoxin increases urine production but its therapeutic effect is not primarily gained from diuresis or blood pressure reduction.
The nurse monitors which client for an increased risk of digoxin toxicity? The client with a peripheral vascular dysfunction The client with renal dysfunction The client with an integumentary dysfunction The client with liver dysfunction
The client with renal dysfunction Explanation: The client with renal dysfunction is at an increased risk for digoxin toxicity.
Which is true about digoxin? Digoxin is used to treat paroxysmal atrial fibrillation. The therapeutic range for digoxin is 0.5 to 2 ng/mL. Digoxin decreases the mortality associated with heart failure. Digoxin improves the quality of life for patients with heart failure in the absence of atrial fibrillation.
The therapeutic range for digoxin is 0.5 to 2 ng/mL. Explanation: The therapeutic range for digoxin is generally considered to be 0.5 to 2 ng/mL. (A lower range of 0.5 to 0.8 ng/mL has been suggested to minimize adverse effects without sacrificing efficacy.) Digoxin has been shown to improve symptoms, increase the quality of life, and increase the exercise tolerance of patients with CHF. These benefits occur regardless of the underlying heart rhythm (normal sinus or atrial fibrillation), the etiology of the heart failure, or other drugs used in therapy (e.g., ACE inhibitors, beta-blockers). Digoxin does not decrease mortality from heart failure. Digoxin is also used in treating chronic atrial fibrillation to maintain a satisfactory resting ventricular rate; it is no longer recommended to prevent paroxysmal (recurrent episodes of) atrial fibrillation.
A group of nursing students are reviewing cardiotonic drugs. The students demonstrate understanding of the information when they identify which adverse reaction associated with cardiotonic medications? Restlessness Constipation Visual disturbances Diarrhea
Visual disturbances Explanation: Adverse reactions associated with cardiotonic medications include headache, weakness, drowsiness, visual disturbances, nausea, anorexia, and arrhythmias. Diarrhea, constipation, and restlessness are not adverse reactions of cardiotonic medications.
A client is receiving digoxin and experiences severe bradycardia. Which medication would the nurse anticipate administering if prescribed? milrinone (Primacor) atropine activated charcoal propafenone
atropine Explanation: If severe bradycardia occurs, atropine may be ordered. Milrinone is a miscellaneous inotropic drug used to treat heart failure. Activated charcoal is an antidote for poisoning with certain toxic substances, but not digoxin. It also decreases serum digitalis levels. Propafenone increases serum digitalis levels and would not be used.
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 intake and output. cognition. exercise tolerance. blood pressure.
blood pressure. Explanation: 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.
A client is being treated for heart failure. What assessment finding would the nurse interpret as most indicative of improved health status? Decreased pitting edema Increased skin turgor Heart rate of 52 Improved sensorium
decreased pitting edemaThe absence of pitting edema, decreased size of ankles and abdominal girth, and decreased weight improves circulation and increases renal blood flow. The diminished fluid volume is indicative of an improved blood supply to the body tissues. Increased skin turgor indicates that the client is well hydrated and does not have fluid volume excess. A heart rate of 52 is too slow to provide good contractility. Improved sensorium indicates adequate perfusion but is not the most indicative of improved heart failure status.
A client newly diagnosed with heart failure questions why the therapy with digoxin will begin with four doses of digoxin rather than the usual one dose, in a 24-hour period. How would the nurse respond? it more accurately gauges the effect of digoxin on your cardiac function it helps confirm that you don't have a hypersensitivity to digoxin it rapidly brings your serum digoxin levels up to therapeutic levels it helps mitigate the potential for adverse effects
it rapidly brings your serum digoxin levels up to therapeutic levels Explanation: Digitalization is the administration of a loading dose (a dose larger than the regularly prescribed daily dosage) of digoxin to reach the therapeutic index rapidly. None of the options accurately describe the reasoning behind this practice of dose loading.
To maximize absorption of digoxin, the nurse would instruct the patient to take the drug: with an antacid. on an empty stomach. with a small glass of water. after a meal.
on an empty stomach. Explanation: Digoxin is absorbed best on an empty stomach.
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. valvular disease. hypertension. coronary artery disease.
renal failure. Explanation: 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.
A client reports seeing halos around lights. The client takes digoxin by mouth every day. The health care provider orders the client to have serum digoxin level drawn. Which of the digoxin levels indicate the client is experiencing toxicity? 4.0 ng/mL 1.0 ng/mL 2.0 ng/mL 0.5 ng/mL
4.0 ng/mL Explanation: Therapeutic serum levels of digoxin are 0.8 to 2 ng/mL. Levels above that would indicate toxicity, and those below would not yet be therapeutic.
A nurse is administering digoxin intravenously as ordered. The nurse would administer the drug over which time frame? 4 minutes 3 minutes 2 minutes 5 minutes
5 minutes Explanation: Intravenous digoxin must be administered slowly over at least 5 minutes to prevent cardiac arrhythmias and adverse effects.
The pharmacology instructor is describing medications that increase the contractile force of the heart. Which term describes this effect? Negative dromotropic Positive chronotropic Positive inotropic Negative inotropic
A positive inotropic effect improves the contractility and pumping ability of the heart.
Which dosage forms are used for digoxin (Lanoxin) maintenance therapy? (Select all that apply.) Injection Patch Tablet Ointment Capsule
Capsule Injection Tablet Explanation: Capsules and tablets are used for maintenance therapy, injections are used for rapid digitalization, and digoxin patches and ointment do not exist.
A patient is prescribed a cardiotonic medication. Which pre-administration assessment should the nurse perform on this patient? Inspect joints for swelling. Obtain blood glucose levels. Check for jugular vein distention. Inspect skin for rash.
Check for jugular vein distention. Explanation: 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.
Which would the nurse identify as a cardiac glycoside? Milrinone Captopril Digoxin Inamrinone
Digoxin Explanation: Digoxin is a cardiac glycoside. Inamrinone and milrinone are phosphodiesterase inhibitors. Captopril is an angiotensin-converting enzyme inhibitor.
Vasodilators used to treat heart failure include nitrates and ACE inhibitors. True False
Drug therapies used to treat heart failure include vasodilators, such as angiotensin-converting enzyme (ACE) inhibitors and nitrates, which decrease cardiac workload, relax vascular smooth muscle to decrease afterload, and allow pooling in the veins, thereby decreasing preload of the heart and helping to improve function.
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? Subcutaneously Intramuscularly Intravenously Orally
Intravenously Explanation: Milrinone (Primacor) is only to be given intravenously. The other routes are not used.
The client's digoxin level is 0.125. How does the nurse interpret this level? Normal Toxic Elevated Low
Low Explanation: The therapeutic serum digoxin level is 0.8 to 2.0 ng/mL. Higher serum levels are associated with an increased risk of adverse effects and toxicity without clear evidence of improved efficacy.
The nurse is caring for a patient receiving cardiotonic drugs. The patient has edema. Which intervention should be taken to alleviate edema? Observation of pulse rate Observation of respiratory rate Auscultation of the lungs Measurement of intake and output
Measurement of intake and output Explanation:Measurement of intake and output is a nursing intervention related to the edema in the patient receiving cardiotonic drugs. Auscultation of the lungs, observation of respiratory rate, and observation of pulse rate are interventions not related to edema in the patient.
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? Give the dose and contact the health care provider. Omit the dose and contact the health care provider. Reduce the dose and contact the health care provider. Omit the dose and inform the oncoming nurse at the next shift change.
Omit the dose and contact the health care provider. Explanation: 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. Reference:
After reviewing the signs and symptoms of heart failure, a student demonstrates understanding when the student identifies which finding as associated with right sided heart failure? Polyuria Dyspnea Hemoptysis Peripheral edema
Peripheral edema Explanation:Peripheral edema would be associated with right-sided heart failure. Hemoptysis, dyspnea, and polyuria would be associated with left-sided heart failure.
A client is experiencing nausea and visual disturbances when taking digoxin. Which medication will be administered? Acetylsalicylic acid Nesiritide Felbamate Digoxin immune fab
Digoxin immune fab Explanation: 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.
A male client is diagnosed with heart failure. The health care provider orders a loading dose of digoxin. Loading doses are necessary for what reason? Oral digoxin is ineffective for the treatment of heart failure. Digoxin's long half-life makes therapeutic serum levels difficult to obtain without loading. Digoxin's short half-life increases the risk for toxicity. The client is at risk for dysthymia with titrated doses.
Digoxin's long half-life makes therapeutic serum levels difficult to obtain without loading. Explanation: Digoxin dosages must be interpreted with consideration of specific client characteristics, including age, weight, gender, renal function, general health state, and concurrent drug therapy. Loading or digitalizing doses are necessary for initiating therapy, because digoxin's long half-life makes therapeutic serum levels difficult to obtain without loading. Loading doses should be used cautiously in clients who have taken digoxin within the previous 2 or 3 weeks.
The nurse is assessing the client for left-sided heart failure. Which symptom would the nurse identify as left-sided failure? (Select all that apply.) Hepatic engorgement Dyspnea Tachycardia Neck vein distention Cough
Dyspnea Tachycardia Cough Explanation: Left-sided heart failure symptoms include a cough, tachycardia, and dyspnea. Right-sided heart failure symptoms include hepatic engorgement, peripheral edema, and neck vein distention.
A male client who is prescribed digoxin asks the nurse how he should take the drug. Which instruction would be most appropriate? "Take the medicine with an antacid at any time of the day." "Take the drug after eating your breakfast." "Take the drug on an empty stomach at the same time each day." "Eat a small snack just before taking the drug."
"Take the drug on an empty stomach at the same time each day." Explanation: 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 client experiences nausea and visual disturbances when taking digoxin (Lanoxin). The nurse would anticipate the client's digitalis level to be: 1.7 nanograms/mL 1.3 nanograms/mL 2.7 nanograms/mL 0.2 nanograms/mL
2.7 nanograms/mL Explanation: 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 female client presents to the emergency department with nausea, vomiting, and a heart rate of 45 beats per minute. Her husband states that she takes digoxin, Lasix, and nitroglycerin for chest pain. Laboratory results confirm digoxin toxicity. The nurse would expect the health care provider to order what medication to treat the bradycardia? Atropine Nitroglycerin Nesiritide Nifedipine
Atropine Explanation: Atropine or isoproterenol, used in the management of bradycardia or conduction defects, may be administered to clients with digoxin toxicity.
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? Milrinone Atropine Cholestyramine Inamrinone
Atropine Explanation: 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.
A nurse is caring for a patient admitted to the intensive care unit because of heart failure. The patient is prescribed digoxin. Which nursing diagnosis would be appropriate for this patient? Risk of Constipation related to adverse effects of the drug therapy Decreased Cardiac Output related to altered cardiac function Risk for Hyperthyroidism related to adverse effects of drug therapy Acute Pain and Headache related to adverse effects of the drug therapy
Decreased Cardiac Output related to altered cardiac function Explanation: Use of digoxin increases the risk for Decreased Cardiac Output related to altered cardiac function from the drug therapy. The use of digoxin does not pose a risk for acute pain, headache, hyperthyroidism, or constipation.
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? ACE inhibitors Digoxin Hydrochlorothiazide Human B type natriuretic peptide
Digoxin Explanation: 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 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? Asthmatic bronchitis Pulmonary edema Heart failure Myocardial infarction
Heart failure Explanation: Cardinal manifestations of HF are dyspnea and fatigue, which can lead to exercise intolerance and fluid retention resulting in pulmonary congestion and peripheral edema. Reference:
When describing cardiotonic drugs, the nurse would expect to include which condition as an indication for use? Select all that apply. Heart failure Atrial fibrillation Hypothyroidism Hyperlipidemia Hypertension
Heart failure Atrial fibrillation Explanation: Cardiotonic drugs are used to treat heart failure if other treatments fail to improve client status and to treat atrial fibrillation. Thyroid hormones are used to treat hypothyroidism. Statin therapy is used in the treatment of hyperlipidemia. Thiazides and loop diuretics are used to treat hypertension along with other antihypertensives.
An instructor is describing positive inotropic activity. Which would the instructor include as a result of this activity? Increased conduction velocity Increased preload Decreased heart rate Increased cardiac output
Increased cardiac output Explanation: Positive inotropes increase cardiac output. Decreased heart rate is a negative chronotropic effect. Increased preload is a result of increased venous tone and circulating volume. Changes in conduction velocity are chronotropic effects, not inotropic.
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? Decreased afterload Increased ventricular rate Increased force of heart contraction Decreased cardiac output
Increased force of heart contraction Explanation: Cardiac glycosides increase the force of cardiac contraction, which increases cardiac output.
The nursing instructor explains to students that positive inotropic action affects the heart in which way? Increased heart rate Decreased ventricular pressures Decreased venous return Increased myocardial contraction
Increased myocardial contraction Explanation: 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 nurse is preparing to administer inamrinone. The nurse would administer this drug most likely by which route? Intramuscular Intravenous Subcutaneous Oral
Intravenous Explanation: Inamrinone is administered only by the intravenous route.
A nurse is required to monitor a client for right ventricular dysfunction. Which would the nurse most commonly assess? Pitting edema Dyspnea Orthopnea Hacking cough
Pitting edema One of the most common symptoms associated with right ventricular dysfunction is pitting edema. The other symptoms of right ventricular dysfunction are nocturia, anorexia, weight gain, and weakness. Dyspnea, orthopnea, and hacking cough are the symptoms associated with left ventricular dysfunction, and not right ventricular dysfunction.
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 Monitor the infant's respiratory rate Monitor the infant's blood pressure Monitor the infant's temperature
Monitor the infant's apical pulse Explanation: 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.)
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? Sodium levels Potassium levels Liver enzymes Electrocardiogram results
Potassium levels Although it is important to monitor the patient's ECG, it is more important to closely monitor potassium levels when the patient 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 patient's sodium levels and liver enzyme levels may need to be monitored periodically, but not as closely as potassium levels.
The nurse is caring for a client receiving digoxin. The nurse would intervene for possible digoxin toxicity when the client exhibits which symptoms? Refusal to eat Sudden disorientation to time and place Reported blurred vision and there are halos around dark objects. Reported feeling of nausea and vomiting in an emesis basin
Refusal to eat Explanation: Catching possible digoxin toxicity at its earliest symptom is important, so the nurse may call the primary care provider (PCP) for an order for a digoxin level. Once the digoxin level is available, the nurse should call the PCP with the result and obtain further orders. Anorexia, which is a reported feeling of a decreased or absent appetite, is the first symptom of possible digoxin toxicity. Later symptoms include nausea, vomiting, headache, confusion, and visual disturbances: Blurred vision and halos over dark objects, and disturbances in yellow and green vision. The client may develop bradycardia, a heart rate below 60 beats per minute, or tachy-arrhythmias, a heart rate that is irregular and greater than 100 beats per minute.
A client has an elevated BUN. The client has been prescribed digoxin for heart failure. What aspect of care is the priority regarding this client? The client should be taught to increase sodium in the diet. The dose should be increased when the heart rate is below 60. The dose should be decreased in this client. The dosage should be 1.0 mg per mouth daily.
The dose should be decreased in this client.The dose must be reduced in the presence of renal failure because most of the digoxin is excreted unchanged by the kidneys, leading to drug accumulation and toxicity. The client should be taught to limit sodium intake in the diet. The client's heart rate should remain above 60. If the heart rate falls below 60, the digoxin should be held. The dose of 1.0 mg is too large for a client with altered renal function.
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 sodium chloride. The patient will be given digoxin immune fab. The patient's digoxin dosage will be reduced. The patient will be monitored to see if symptoms resolve without action.
The patient will be given digoxin immune fab. Explanation: 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).
