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Iggy Chapter 32: Concepts of Care f...

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IGGY Nursing Management: Acute K...

36 terms superusenurse Preview Iggy C 147 term Axe The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8 Pulse: 48 and irregular Respirations: 20 Potassium level: 3.2 mEq/L What action does the nurse take?

• Give digoxin; reassess the heart rate in 30 minutes.
• Give the digoxin; document assessment findings in the medical record.
• Hold the digoxin, and obtain a prescription for an additional dose of furosemide.
• Hold the digoxin, and obtain a prescription for a potassium supplement.

Answer: Hold the digoxin, and obtain a prescription for a potassium supplement

Rationale: Digoxin causes bradycardia; hypokalemia potentiates digitalis. The nurse seeks to correct this situation through collaboration with the provider.A client with heart failure has furosemide (Lasix). Which finding would concern the nurse with this new prescription?

• Serum sodium level of 135 mEq/L
• Serum potassium level of 2.8 mEq/L
• Serum creatinine of 1.0 mg/dL
• Serum magnesium level of 1.9 mEq/L

Answer: Serum potassium level of 2.8 mEq/L

Rationale: Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy

In monitoring the diagnostic test of a client admitted with heart failure (HF), which finding is consistent with this diagnosis?

• Serum potassium level of 3.2 mEq/L
• Ejection fraction of 60%
• B-type natriuretic peptide (BNP) of 760 ng/dL
• Chest x-ray report showing right middle lobe consolidation

Answer: B-type natriuretic peptide (BNP) of 760 ng/dL

Rationale: BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure?

• Ibuprofen (Motrin)
• Hydrochlorothiazide (HydroDIURIL)
• NPH Insulin
• Levothyroxine (Synthroid)

Answer: Ibuprofen (Motrin)

Rationale: Long-term use of NSAIDs, such as ibuprofen (Motrin), causes fluid and sodium retention The client begins therapy with lisinopril (Prinivil, Zestril). What should the nurse consider at the start of therapy with this medication?

• The client's ability to understand medication teaching
• The risk for hypotension
• The potential for bradycardia
• Liver function tests (LFTs)

Answer: The risk for hypotension

Rationale: Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years.The nurse is caring for a client with heart failure. For which symptoms should the nurse assess? Select all that apply.

• Chest discomfort or pain
• Tachycardia
• Expectorates thick, yellow sputum
• Sleeps on back without a pillow
• Shortness of breath with exertion

Answer: Chest discomfort or pain; Tachycardia; Shortness of breath with exertion

The nurse caring for a client discusses the importance of restricting sodium in the diet. Which statement made by the client indicates that he needs further teaching?

• "I should avoid grilling hamburgers."
• "I must cut out bacon and canned foods."
• "I shouldn't put the salt shaker on the table anymore."
• "I should avoid lunch meats but may cook my own turkey."

Answer: "I should avoid grilling hamburgers."

Rationale: Cutting out beef or hamburgers made at home is not necessary; however, fast food hamburgers are to be avoided owing to higher sodium content.The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply.

• Hypokalemia
• Sinus bradycardia
• Fatigue
• Serum digoxin level of 1.5
• Anorexia

Answer: Sinus bradycardia; Fatigue; Anorexia

The nurse recognizes that which medication when given in heart failure may improve morbidity and mortality?

• Dobutamine (Dobutrex)
• Carvedilol (Coreg)
• Digoxin (Lanoxin)
• Bumetamide (Bumex)

Answer: Carvedilol (Coreg)

Rationale: Beta-adrenergic blockers reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; they improve morbidity, mortality, and quality of life How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen?

• Ejection fraction is 25%.
• Client states that she is able to sleep on one pillow.
• Client was hospitalized five times last year with pulmonary edema.
• Client reports that she experiences palpitations.

Answer: Client states that she is able to sleep on one pillow

Rationale: Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy?

• Client ambulates around the nursing unit with a walker.
• The nurse monitors the client's pulse and blood pressure frequently.
• The nurse obtains a bedside commode before administering furosemide.
• The nurse returns the client to bed when he becomes tachycardic.

Answer: The nurse obtains a bedside commode before administering furosemide.

Rationale: Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand.Which intervention will best assist the client with acute pulmonary edema in reducing anxiety and dyspnea?

• Monitor pulse oximetry and cardiac rate and rhythm.
• Reassure the client that his distress can be relieved with proper intervention.
• Place the client in high Fowler's position with the legs down.
• Ask a family member to remain with the client.

Answer: Place the client in high Fowler's position with the legs down

Rationale: High Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.The nurse is providing discharge teaching to the client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates understanding of the teaching?

• "I will call the provider if I have a cough lasting 3 or more days."
• "I will report to the provider weight loss of 2 to 3 pounds in a day."
• "I will try walking for 1 hour each day."
• "I should expect occasional chest pain."

Answer: "I will call the provider if I have a cough lasting 3 or more days." Rationale: Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified.A client admitted for heart failure has a priority problem of Excess Fluid Volume related to compromised regulatory mechanisms. Which of these assessment data obtained the day after admission is the best indicator that the treatment has been effective?

• The client has a diuresis of 400 mL in 24 hours.
• The client's blood pressure is 122/84 mm Hg.
• The client has an apical pulse of 82 beats/min.
• The client's weight decreases by 2.5 kg.

Answer: The client's weight decreases by 2.5 kg.

Rationale: The best indicator of fluid volume loss is daily weight; because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid.