HESI Case Study- Aortic Regurgitation

The nurse administered the first doses of digoxin and furosemide at 0800. What is the earliest time the second dose of digoxin can be given?

1400 as instructed.

Discharge planning is started with the admission process. With the information that the nurse has gathered, which intervention is most important for the nurse to include in the client's discharge plan?

Identify available community resources.

Which intervention is most important for the nurse to include in the client's plan of care to decrease risk of having a myocardial infarction?

Identify the client's risk factors for having an acute myocardial infarction

Therapeutic communication involves listening and analyzing what the client is conveying. Based on the information provided by the client, which nursing interventions best promotes effective communication? (Select all that apply. One, some, or all options may be correct.)

Inquire about the client's work history including specific job duties. Assist the client in recalling his diet intake over the last few weeks. Review with the client any family history of cancer. Question the client regarding history of military enlistments.

During client education, the client reports to the nurse that even though breathing is easier, they do not like the dizzy feeling they experience when changing positions or when getting out of bed. Which nursing intervention best promotes effective communication?

Instruct the client to change positions and stand slowly.

Upon reviewing the prescriptions and laboratory results, which intervention(s) should the nurse include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.)

Ensure NPO instructions are clarified with HCP. Discuss plan to correct abnormal laboratory values with HCP.

The severity of the client's pleural effusions are confirmed with the enlarged cardiac silhouette on the chest x-ray. The client is having difficulty taking deep breaths and is short of breath when speaking. Which intervention is most important for the nurse to include in the client's plan of care?

High Fowler's positon.

The nurse notices that the client's urine is greenish in appearance when a urine sample is collected. Which intervention(s) should the nurse implement? (Select all that apply. One, some, or all options may be correct.)

Ask the client to list the food he has eaten in the last 24 hours. Record the color and amount of urine in the medical record.

The ED nurse looks up the prescribed medications and notes that the recommended dosage for losartan is 50 mg PO daily, or 25 mg PO daily in combination with a diuretic. A precaution listed for this medication is increased risk of hypotension and syncope with concurrent use of ACE inhibitors. What action should the nurse implement?

Contact the HCP to clarify medication prescriptions.

Later that day, the client reports to the nurse less abdominal pain and nausea, a severe headache, blurry vision, and feels really tired. The nurse assesses the client and notes an irregular heart rate of 56 bpm. Which laboratory tests does the nurse anticipate the HCP will prescribe for the client? (Select all that apply. One, some, or all options may be correct.)

Digoxin serum level. Potassium serum level.

Which intervention should the nurse initiate first?

Place the client on a stretcher and open airway.

As the client is transferred to a stretcher the nurse notices the use of accessory muscles of the chest and neck and an exaggerated effort to breathe. Which intervention should the nurse implement first?

Raise the head of the stretcher to a semi-Fowler's position

The nurse teaches the client about their medications prior to administering them. Which intervention is most important for the nurse to include regarding the amlodipine and diltiazem which are both calcium-channel blockers?

Report any episodes of dizziness.

The client is having periods of confusion and appears weak and fatigued. The client tells the nurse they feel like their heart is fluttering at times. Which laboratory value(s) could be related to the client's symptoms? (Select all that apply. One, some, or all options may be correct.)

Sodium Potassium Blood Urea Nitrogen Phosphorus

The nurse verified the prescriptions and the dose to be given to the client. When preparing to administer the furosemide, which assessment finding(s) warrant intervention by the nurse? (Select all that apply. One, some, or all options may be correct.)

Tenderness at the IV insertion site. Occasional premature ventricular complexes.

The client is transferred from the ED to the medical unit. The ED nurse gives the admitting nurse a hand-off report. Which nursing intervention best promotes effective communication?

Use SBAR (Situation-Background-Assessment-Recommendation) when reporting to receiving nurse.

Based on the diagnostic findings with the physical assessment of dullness with percussion, which assessment finding warrants immediate intervention by the nurse?

Use of accessory muscles.

Calcium channel blockers enhance the action of digoxin by increasing the serum digoxin levels. Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity?

Yellow halos around lights.

The HCP plans to keep the client in the hospital for a few days. The ED nurse is preparing to transfer the client to a medical unit. Which intervention should the nurse implement first?

Call to provide a report to the receiving nurse.

It is important for the nurse to develop a therapeutic relationship with the client. When conducting the admission interview, what actions best facilitate the process? (Select all that apply. One, some, or all options may be correct.)

Clarify information by questioning the client to verify information. Let the client do most of the talking and actively listen. Use closed-ended questions to keep the client from straying from the topic.

The nurse completes a problem focused assessment. Which finding warrants immediate intervention by the nurse?

Irregularly, irregular atrial dysrhythmia.

The nurse assesses the client's fall risk factors and determines they score a moderate fall risk. What change(s) in the client's care should the nurse tell him to expect? (Select all that apply. One, some, or all options may be correct.)

Two side rails up while in bed. A UAP will assist with trips to the bathroom. Non-skid footwear to be worn while out of bed.

he client is settled in and the the nurse is planning the client's care. Based on the prescriptions provided, which actions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply. One, some, or all options may be correct.)

Weigh the client on the medical unit's scale. Place the cardiac monitor on the client. Put a fluid restriction sign at the head of bed