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21 Cards in this Set
- Front
- Back
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Heart failure most commonly occurs in clients over the age of 60, and occurs more commonly in males than females
1) in addition to these risk factors, which question will provide the nurse the best data about an additional risk factors for heart failure? |
Have you ever had a heart attack? |
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2) which assessment finding would indicate to the nurse that Bert is experiencing right-sided heart failure? |
edema |
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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 unit, Bert's dyspnea continues. He reports fatigue but denies chest pain. The nurse places Bert on oxygen via 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 Bert's pulse rate, which is 136 and irregular.
3) Which cardiac dysrhythmia is Bert most likely experiencing? |
Atrial fibrillation |
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4) Based on bert's cardiac dysrhythmia, which action should the nurse implement first? |
administer a prescribed dose of digoxin (Lanoxin) |
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Bert is scheduled for a chest xray and a 12 lead ECG. Additional diagnostic studies that may be performed include echocardiography and pulmonary artery catherization
5) which of these diagnostic tests is used to measure the pressure within the atrium? |
pulmonary artery catherization |
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7) which assessment is most important for the nurse to perform prior to administering captopril (Capoten)? |
blood pressure |
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8) the nurse explains to bert that docusate sodium (Colace) has been prescribed for what purpose? |
prevent straining during bowel movement |
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9) the nurse assesses for which expected outcome of digoxin therapy? |
serum digoxin level of 1.0 ng/mL |
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Bert's nurse is developing his plan of care
10) which nursing Dx should be included in the plan of care? |
impaired gas exchange |
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11) which intervention should be implemented based on the Dx of activity intolerance? |
encourage frequent rest periods |
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the nurse enters bert's room and finds bert lying in bed in a supine position. his RR is 32/min and he states that his back hurts.
additional interventions implemented by the nurse included monitoring ECG, vitals, degree of peripheral edema, and daily weights. the nurse also monitors oral and iv fluid intake. the nurse reviews the lab work to monitor serum electrolytes, especially the K level. coagulation profile, specifically the INR/PTT therapeutic range. the nurse also places bert on fall precautions.
bert responds well to the plan of care. the nurse initiates client teaching regarding his med management in anticipation of his DC.
12) which action should the nurse implement first? |
elevate the head of bert's bed |
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13) what additional instructions should the nurse include in bert's teaching plan? |
- do not stop taking any prescribed K supplements - regular blood draws will be necessary to measure prothrombin time (PT) and INR |
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Bert is DCed from the acute care setting and resumes living at home. his daughter checks on him frequently.
14) bert has been taking alpha-adrenergic blocker carvedilol (Coreg) 3.125 mg PO BID. What info is most important for the nurse to provide bert? |
avoid abrupt transitions to an erect posture |
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15) bert will be going home on capoten 12.5 mg PO BID. What info is most important for the nurse to include in DC teaching and document in the EMR? |
signs of angioderma |
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16) bert is now on furosemide 20 mg PO BID. Bert is aware this med increases his urinary output. he asks the nurse how furosemide helps his heart. what topic info should be included in the nurse's teaching? |
reduction of cardiac preload |
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bert returns to the clinic several weeks later. he complains to the nurse that he has a headache and is seeing double. he reports that he is currently taking digoxin, furosemide, and 1 aspirin a day. the nurse notes that he has had 2 diarrhea stools that day and his PR is 62 beats/min and irregular with frequent ectopic beats.
17) what is the most important intervention for the nurse to implement? |
obtain a serum K level |
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18) what imbalance places the client taking digoxin at greatest risk of toxicity and associated dysrhythmias? |
hypercalcemia |
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19) what manifestations are early indications of digitalis toxicity? |
anorexia, nausea, and vomiting |
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20) which electrolyte should be closely monitored in just a few hours after treatment with Digibind? |
potassium |
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the charge nurse is making client care assignments
21) which member of the nursing staff would be best assigned to bert while he is receiving treatment for his digitalis toxicity? |
an experienced critical care RN who has been assigned to float on the unit |
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during bert's treatment with digibind, the nurse assesses that he is becoming increasingly confused and restless, and that he has developed a frothy, productive cough. his vitals are T: 98 P: 148 BP: 110/64 R: 36
22) which nursing intervention should the nurse implement first? |
obtain an O2 sat lvl via pulse ox |
