Case Study Aortic Regurgitation

Correct Incorrect Question 3 of 23 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? Arrange a follow-up appointment with a healthcare provider. Follow up will be key upon discharge; however, if risks are not modified, follow up will not help reduce the risk. Obtain a consult for social worker to provide community resources. Resources are important, but will not directly reduce the risk. Call the local pharmacy to identify the antihypertensive that the client was prescribed. Knowing what medication the client was taking will not directly decrease his risk. Identify the client's risk factors for having an acute myocardial infarction. Identifying and informing the client of the risk factors that can be modified is priority. Smoking, drinking, and hypertension are modifiable and/or controllable risk factors. Family history will also increase the client's risks. Question 4 of 23 The nurse completes a problem focused assessment. Which finding warrants immediate intervention by the nurse? Irregularly, irregular atrial dysrhythmia. An irregularly, irregular atrial dysrhythmia, known as Atrial Fibrillation is a complication of heart failure. Atrial fibrillation increases as the severity of heart failure increases and promotes thrombus formation within the atria which can break loose and place the client at risk for a life-threatening stroke. Lewis, Sharon. (2017). Medical-surgical nursing assessment and management of clinical problems (10th ed.). St. Louis, MO. Elsevier. pp. 742-743. Progressive weight gain. Progressive weight gain is a clinical manifestation of chronic heart failure and is not immediatly life threatening. Fatigue with usual activities. Fatigue with usual activities is a clinical manifestation of chronic heart failure and is not immediatly life threatening. Dyspnea with mild exertion. Dyspnea with mild exertion is a clinical manifestation of chronic heart failure and is not immediatly life threatening. Question 7 of 23 Based on the diagnostic findings with the physical assessment of dullness with percussion, which assessment finding warrants immediate intervention by the nurse? Progressive dry cough. A dry cough is a common symptom for pleural effusions, but is not life threatening. Decreased breath sounds. The infiltrates are areas of the lungs where there are decreased breath sounds caused by pulmonary edema as a result of heart failure. Use of accessory muscles. Use of accessory muscles is a sign that the client is failing to compensate and may require life-saving measures. Lewis, Sharon. (2017). Medical-surgical nursing assessment and management of clinical problems (10th ed.). St. Louis, MO. Elsevier. pp. 456-457; 743. Dyspnea on exertion. The client can limit activities that cause dyspnea and may need to be placed on bed rest if oxygenation falls below 94% with activity. Question 13 of 23 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.) Keep the client on bedrest until oxygen can be weaned. The client does not need to be placed on bedrest unless there is a suspicion of a more serious problem such as a pulmonary embolism. Mobility as tolerated decreases risk of pulmonary complications. Ensure NPO instructions are clarified with HCP. The client should be on NPO status for a minimum of 8 hours for the fasting glucose and 12 hours for the lipid profile. Potter, Patricia and Ostendorf, Wendy and Perry, Anne. (2020). Nursing interventions & clinical skills (7th ed.). St. Louis, MO: Elsevier. p. 212. Discuss plan to correct abnormal laboratory values with HCP. The client's abnormal sodium, potassium, and phosphorus need to be addressed. Abnormalities can cause cardiac irritability and lethal arrhythmias. Crawford, Lynne. (2020). Fundamentals of nursing (2nd ed.). St. Louis, MO: Elsevier. p. 962. Increase the frequency of vital signs. The order for vital signs every four hours should be sufficient unless the client’s condition decompensates. Clarify rate of IV fluids while NPO. Increasing the client’s IV fluid would exacerbate his congestive heart failure. Question 14 of 23 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? In the morning with breakfast. First and second dose of digoxin prescription is the loading dose, The second dose should be administered 6 hours after the first dose at 1400. 0815 as instructed. First and second dose of digoxin prescription is the loading dose. The second dose should be administered 6 hours after the first dose at 1400. 1400 as instructed. Pay attention to order details. First and second dose of digoxin prescription is the loading dose. The second dose should be administered 6 hours after the first dose at 1400. Crawford, Lynne. (2020). Fundamentals of nursing (2nd ed.). St. Louis, MO: Elsevier. p. 450. 0900 as instructed. First and second dose of digoxin prescription is the loading dose. The second dose should be administered 6 hours after the first dose at 1400. Question 15 of 23 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.) Some correct answers were not selected Tenderness at the IV insertion site. The intravenous site should be assessed a minimum of every two hours and whenever getting ready to initiate an IV medication. Tenderness may be a sign of infection or infiltration and requires further assessment. Potter, Patricia and Ostendorf, Wendy and Perry, Anne. (2020). Nursing interventions & clinical skills (7th ed.). St. Louis, MO: Elsevier. p. 723. Blood pressure 160/90 mmHg. The baseline blood pressure and pulse before administering the diuretic bolus and during the administration should be assessed. A diuretic may lower blood pressure which would be desirable in this scenario. Occasional premature ventricular complexes. Occasional premature ventricular complexes (PVCs) is a sign of cardic muscle irritability. The client has a low potassium and sodium level. Administering a diuretic will increase the urine output and may lower the value of the electrolyes more. the PVCs should be reported and electrolytes assessed before administering a diuretic. The client’s bladder. Assessment of the bladder is not necessary, unless the client is experiencing urinary retention which may require a urinary catheterization prior to the administration of the furosemide 40 mg IV. The client’s potassium level for any pre-existing hypokalemia. Monitor electrolytes, particularly potassium, before and during therapy. Question 18 of 23 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. Once the client is discharged, community resources can address his healthcare, financial, transportation needs. The resources will be key in the client's overall well-being. Ensure the client that they will have a room at the homeless shelter. Discharging the client to the street is not an option; however, community resouces may be able to identify adequate housing. Teach the cliernt about foods high in protein. It is important for the client to increase foods that will improve the dietary anemia; however, without resources to purchase food. Schedule follow-up appointments. The client will need to follow-up with a HCP after discharge, however, without resources he will not have transportation. Question 20 of 23 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? Low potassium level. Potassium can increase or decrease the effects of digoxin but is not a sign of toxicity. Yellow halos around lights. Early signs of toxicity include anorexia, nausea and vomiting, fatigue, headache, depression, and visual changes. Slow heart rate. Late signs of toxicity include cardiac dysrhythmias such as bradycardia or heart blocks. Increased liver function test. Digoxin is metabolized by the kidneys and liver. If the client has kidney or liver disease, they have an increase in risk for toxicity; however, this is not a sign of toxicity.