Heart Failure with Atrial Fibrillation
The client will be going home on carvedilol 12.5mg PO BID. Choose the most important side effect for the nurse to include in the discharge teaching and document in the electronic medical record (EMR)
Answer: B. Slow pulse rate Overdose can produce profound bradycardia, hypotension, and bronchospasm, all of which can be life threatening. A. Development of cough B. Slow pulse rate C. Dizziness upon standing D. Onset of nausea
In an effort to monitor his HF, what is the most important intervention that the client can perform at home?
Answer: C. Weighing every day on the same scale Daily weights are the most important intervention for monitoring HF A. Check radial pulse 6x a day, upon arising, at each meal and before bed B. Take weekly ankle measurements to monitor edema C. Weighing every day on the same scale D. Incorporate a regular exercise routine
How would this reading be interpreted by the nurse?
Answer: D. Respiratory acidosis Respiratory acidosis is diagnosed with the PaCO2 is high and the pH is low. A. Mild hypoxemia B. Metabolic acidosis C. Severe hypoxemia D. Respiratory acidosis
The nurse prepares the dose of digoxin 0.125mg IV push. The med is supplies as 0.25mg in 2mL. How many mL should the nurse prepare to give?
D/H x V = X Answer: 1
Medication Administration
The HCP prescribes the following medications: 1. Digoxin 0.125 mg IV q6h x4 doses then 0.25mg PO QD. 2. Furosemide 40 IV push qd. 3. Captopril 12.5mg tid. 4. Docusate sodium 100 mg PO BID 5. Carvedilol 3.125 PO BID 6. Warfarin 5mg PO qd
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.
Diagnostic studies
The client is scheduled for a chest x-ray, 12 lead ECG and an echocardiogram
A client visits the healthcare clinic complaining of increasing fatigue and difficulty breathing. Physical assessment findings include a rapid, irregular heart rate of 138 beats/min, blood pressure of 140/86 mmHg, and a respiratory rate of 28 breaths/min. The client's breath sounds are clear with fine crackles in the bases bilaterally. Also noted is positive jugular vein distention (JDV) bilaterally and 1+ pitting ankle edema bilaterally. The client's initial medical diagnosis is heart failure (HF) and they are immediately admitted to the acute care facility for further evaluation and treatment.
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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.
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The client's initial admission prescriptions include: continuous cardiac monitoring. IV: 1,000 mL sodium chloride 0.9% with 40 mEq, KCl at 7mL/hr. Digoxin immune FAB 38 m 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.
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The daughter makes the decision that CPR and mechanical ventilation should not be initiated on her father
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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, and PaO2 52 mmHg.
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The client has been taking alpha-adrenergic blocker carvedilol 3.125mg PO BID. Which interventions are important for the nurse to include in the client's discharge plan? (SATA)
Answer: A. 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). C. Take with food and restrict salt and alcohol intake Carvedilol works best if you take it with food D. Do not quickly discontinue this medication Stopping the medication suddenly may make the condition worse E. 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. A. Avoid abrupt transitions to an erect posture B. Expect full antihypertensive effect noted in 4 weeks. C. Take with food and restrict salt and alcohol intake D. Do not quickly discontinue this medication E. Do not take extra medicine to make up a missed dose
Select additional instruction(s) the nurse should include in the client's teaching plan (SATA)
Answer: A. Monitor BP prior to the administration of digoxin It is necessary to monitor BP while receiving digoxin. D. 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. E. 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. A. Monitor BP prior to the administration of digoxin B. Immediately report a cold or sore throat to your HCP C. If a dose of digoxin is missed, double the next dose D. Do not stop taking any prescribed potassium supplements. E. Regular blood draws will be necessary to measure prothrombin time (PT) and INR
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? (SATA)
Answer: A. Social Worker B Clergy person . C. Healthcare providers D. The client's extended family ---They are an integral part of the team, and should be consulted regarding end-of-life decision A. Social Worker B Clergy person . C. Healthcare providers D. The client's extended family E. Hospital administrators
The client is now on furosemide 20mg PO BID. The client is aware that this medication increases urinary output. Which intervention should be included in the client's discharge teaching? (SATA)
Answer: A. Wear sunblock and long sleeves when out in the sun --- furosemide is photosensitive D. Swollen skin remains indented after being pressed - pitting edema is a sign of fluid retention. Therefor the diuretic dosage may need to be increased. E. Report dry mouth and excessive thirst - excessive thirst may be an indication of dehydration, requiring a decreased in the medication B. Measure daily urine output C. Expect anorexia and nausea D. Swollen skin remains indented after being pressed E. Report dry mouth and excessive thirst
After the client's cardiac rhythm is confirmed, which action should the nurse implement next?
Answer: A. Administer a prescribed 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. A. Administer a prescribed stat dose of digoxin B. Notify the HCP of the dysrhythmia C. Transfer the client to the MICU D. Prepare for synchronized cardioversion
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?
Answer: A. Monitor INR lvls 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 decreased the risk of a life-threatening bleed. A. Monitor INR lvls every 4-6 weeks B. Use soft toothbrush to minimize bleeding gums C. Use electric razors for shaving D. Avoid contact sports and hobbies
The best nursing action in response to this decision would be to?
Answer: A. Notify the HCP of the daughter's wishes Do not resuscitate (DNR) orders must be written by the HCP to be legally binding A. Notify the HCP of the daughter's wishes B. Notify the hospital supervisor of the daughter's wishes C. Writes a "DNR per family wishes" order D. Place an arm band on the client that reflects the code status
While applying supplemental oxygen, which intervention is priority for the nurse to initiate?
Answer: A. Position patient upright unless contraindicated and give O2 by nasal cannula or non-rebreather mask 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. A. Position patient upright unless contraindicated and give O2 by nasal cannula or non-rebreather mask B. Obtain baseline vital signs, including O2 sat. C. Auscultate heart for regularity and breath sounds for crackles D. Initiate suctioning to remove lung secretions
Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity?
Answer: B. Anorexia, nausea, and vomiting GI symptoms are among the earliest symptoms of digoxin toxicity, along with confusion and fatigue. Additional manifestations include headache, hypotension, and cardiac dysrhythmias A. BP 180/100 B. Anorexia, nausea, and vomiting C. Pitting dependent ankle edema D. Blurred vision and halo vision
After administration of the prescribed captopril, which assessment finding warrants intervention by the nurse?
Answer: B. Decreased in baseline BP Captopril is an angiotensin converting enzyme (ACE) inhibitors used as an antihypertensive agent. ACE inhibitors have been shown to prolong surivial in clients with HF. By lowering BP (reduced afterload), the workload on the heart is reduced. The nurse should monitor the client's BP to ensure that the medication is having the desired effect, and that hypotension does not occur. Excess hypotension and hyperkalemia may occurs. Monitor the client for first-dose hypotension. A. Complaint of lightheadedness B. Decreased in baseline BP C. Onset of dry and persistent cough D. A decrease in HR
Based on the electrocardiogram rhythm strip, what intervention should the nurse implement first?
Answer: B. 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 occurring. A-fib commonly occurs in HF. 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. A. Ensure the client has 2 large bore IV sites B. Obtain a 12 lead ECG C. Gather supplies to obtain venous blood to be sent to the lab D. Prepare the client for elective cardioversion
What is the most important intervention for the nurse to implement?
Answer: B. Obtain a serum potassium level The client is exhibiting signs of digitalis toxicity and hypokalemia (low potassium). The nurse should immediately obtain significant lab values, including serum potassium and digoxin lvls. Hypokalemia potentiates the effect of digoxin and can result in digoxin toxicity. Serum potassium lvls should range between 3.5-5.0 mEq/L. If the potassium value us 3.0 or less, the nurse should withhold the dose of digoxin, and notify the HCP A. Asses the consistency and the amount of diarrhea B. Obtain a serum potassium lvl C. Obtain a prescription for an analgesic for the client's headache D. Instruct the client to withhold the next daily dose of aspirin.
After treatment with digoxin immune FAB, which of the client's serum lab values requires intervention by the nurse?
Answer: B. Potassium 3.2 mEq/L A precipitous drop in serum potassium may occur after treatment with digoxin immune FAB. A. Calcium 12mg/dL B. Potassium 3.2 mEq/L C. Magnesium 1.94mg/dL D. Phosphorus 4.64mg/dL
Which of the client's serum lab values requires intervention by the nurse?
Answer: C. Calcium 16mg/dL 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 lvls, the nurse should also monitor serum magnesium lvls. Hypomagnesemia is also a contributing factor to digitalis toxicity and it can cause dysrhythmias, hypotension, and tachycardia. A. Hemoglobin 129gL B. WBC 12,000/mcL C. Calcium 16mg/dL D. Albumin 3g/dL
What is the first action that the nurse should implement when entering the client's room?
Answer: C. Elevate the head of the client's bed Since the nurse knows that the client is already experiencing impaired gas exchange and is not obviously dyspneic, the first priority is to reduce 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 sat. should be monitored via pulse oximetry, and supplemental O2 should be provided to maintain adequate oxygenation. Additional assessment includes breath sounds, RR, rhythm, and effort. A. Notify the respiratory therapist B. Assist the client to turn on his side C. Elevate the head of the client's bed D. Offer the client a back massage
Which assessment finding provides the earliest indication that the client is experiencing right-side HF?
Answer: C. Peripheral Edema Right-sided HF 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. A. Dyspnea at rest B. Sinus tachycardia C. Peripheral edema D. Lack of energy
The nurse is monitoring the client's serum electrolytes. Which of the client's serum laboratory values requires intervention by the nurse?
Answer: C. Potassium 3.0 mEq/L Normal potassium is 3.5-5.0 mEq/L. The diuretic 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. A. Digoxin 2.0ng/mL B. Sodium 135 mEq/L C. Potassium 3.0 mEq/L D. Calcium 8.72 mg/dL
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?
Answer: C. Report a gain of 3lbs/ week A weight gain of 3lbs in 2 days or 3-5 pounds in a week should be reported immediately. This may indicate an exacerbation of the HF which requires immediate intervention A. Weigh at the same tie of day B. Keep a record of daily weights C. Report a gain of 3lbs/ week D. Inform healthcare provider of ankle swelling.
The client's daughter and the nurse should utilize which source during this decision-making process?
Answer: C. 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 best resource to help the daughter and the nurse to determine the course of action that client would want if they w3ere able to make a decision at this time. A. The nursing code of ethics B. The hospital's risk management team C. The client's documented wishes for life-saving measures D. The client's case manager
Know that the client has 2 risk factors that cannot be modified, which intervention is most important for the nurse to include in the client's plan of care?
Answer: Complete a focused cardiac history assessment MI, CAD, and ischemic heart disease are among the most common underlying causes of HF. In fact, the most common cause of HF is MI. The nurse should also ask the client if they have HTN which is another primary underlying condition cause HF. A. Identify any history of lung disease B. Complete a focused cardiac history assessment C. Evaluate the client's lower extremities for varicosities D. Review hx for episodes of hypotension
The nurse's best response in this situation would be what?
Answer: D. "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 A. "I'm glad to see you are getting some rest." B. "Do you have someone to sit with you?" C. "Withdrawing will not help your father." D. "You are going through a very difficult time."
Which member of the nursing staff would be best assigned to the client while they are receiving treatment for his digoxin toxicity?
Answer: D. An experienced critical 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 A. A practical nurse (PN) from an agency pool who states that he has 5 years of med-surg experience B. A PN who has worked on the Cardiac Observation Unit for the last 2 years C. A new graduating registered nurse (RN) who has just completed a 4-week orientation on the unit D. An experienced critical RN who has been assigned to "float" on the unit
When preparing the client for the echocardiogram, which intervention should the nurse implement?
Answer: D. Ask the client to lay on their left side during the test The echocardiogram records direction and flow of blood through the heart and transforms it to audio and graphic data that measures valve abnormalities, congenital heart defects, wall motion, EF, and heart function. The best results are obtained when the patient is in a left side lying position. A. Set-up treadmill for initial test B. Instruct the client to fast for at least 6 hours prior to the test C. Ensure the client is wearing comfortable clothes and shoes D. Ask the client to lay on their left side during the test
The nurse observed a family member brining the client food from home. Which intervention is most important for the nurse implement?
Answer: D. Teach the client and his family what foods are low in sodium. Poor adherence to a low-sodium diet is one of the main reason clients are readmitted to the hospital. Teaching and providing diet options are priority. A. Write a low sodium diet on the white board in the client's room B. Record the meal in the electronic medical record C. Instruct the family to inform the nurse when bringing in food. D. Teach the client and his family what foods are low in sodium.
Which menu selection by the client indicates that effective teaching has taken place?
Answer: Fruit snack 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. A. Canned tomato soup and a bologna sandwich on whole wheat bread B. Fruit snack to include bananas, oranges, dried apricots C. Sliced ham, rice seasoned with salt substitute, and canned fruit cocktail D. Veggie burger, french fries, cookies, and a diet soda
In response to the nurse's remark ,the daughter looks down at the floor, and remains silent. Choose the best nursing action to implement in response to the daughter's behavior.
Answer: Stay seated next to the daughter and remain quietly attentive. Silence and offering one's presence are effective therapeutic techniques to encourage communication A. Stay seated next to the daughter and remain quietly attentive B. Turn on the TV to provide the daughter with a distraction C. Provide the daughter with palliative care pamphlets D. Leave the waiting room quietly to show respect for the daughter and to provide her privacy.
Diet Teaching and Weight Management
Diet teaching and weight management are essential. The nurse interviews the client and obtains a detailed diet hx.
A Complication Occurs
During the client's treatment with digoxin immune FAB, the nurse assesses increasing confusion, restlessness, and development of a frothy productive cough. The client's vital signs are: temp: 98.6, HR, 148 beats/minute, RR 36, and BP 120/80 mm/Hg
Risk Factors
HF results in the inability of the heart to provide sufficient blood flow to meet the oxygen needs of the body's tissues and organs. HF occurs most commonly in clients over the age of 60, and occurs more commonly in males than females
Cardiac dysrhythmias
Left-sided HF results in pulmonary fluid overload, and right-sided HF results in peripheral fluid overload. Left-sided HF usually occurs first, and can trigger right-sided HF. 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 3L/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.
Clinical Manifestations
Right-sided (right ventricular) heart failure often occurs due to left-side 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-side HF.
Ethical-Legal Issues: Decisions about Resuscitation
The client is exhibiting symptoms consistent with pulmonary edema. This life-threatening complication of HF 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 sever dyspnea. The priority nursing diagnosis is "impaired gas exchange". The client is placed on oxygen via nasal cannula at 5L/min, and is transferred to the MICU, where IV diuresis is initiated. The client's condition is critical, disoriented and difficult to arouse. The nurse explains to the client's daughters that the oxygenation lvl 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.
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 aspirin each day. The client also reports having diarrhea stools that day. The client's pulse rate is 62 beats/ min and irregular with frequent ectopic beats.
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 COU, 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
Nursing Interventions
The nurse enters the client's room and finds the client lying supine in bed with a RR of 32 breaths/min 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 lab 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.
Therapeutic Communication: Nonverbal Cues
While the client is the 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.
