Heart Failure with Atrial Fibrillation Case Study

1. Knowing that the client has two risk factors that cannot be modified, which intervention is most important for the nurse to include in the client's plan of care? Complete a focused cardiac history assessment. 2. Which assessment finding provides the earliest indication that the client is experiencing right-sided heart failure? Peripheral edema 3. Based on the electrocardiogram rhythm strip, what intervention should the nurse implement first? Obtain a 12 lead ECG 4. After the client's cardiac rhythm is confirmed, which action should the nurse implement next? Administer and ordered stat dose of digoxin 5. When preparing the client for the echocardiogram, which intervention should the nurse implement? Ask the client to lay supine 6. The RN charge nurse prepares a dose of digoxin 0.125 mg IV push. The medication is supplied as 0.25 mg in 2 mL. How many mL should the RN prepare to give? (Enter numeric value only. If rounding is necessary, round to the whole number.) 1 7. After administration of the prescribed captopril, which assessment finding warrants intervention by the nurse? Decrease in baseline blood pressure 8. The nurse is monitoring the client's serum electrolytes. Which of the client’s serum laboratory values requires intervention by the nurse? Potassium 3.0 9. 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? Monitor INR levels 10. The nurse observed a family member bringing the client food from home. Which intervention is most important for the nurse implement? Teach the client and family what foods are low in sodium 11. 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? Report a weight gain of 3lbs in one week 12. What is the first action that the nurse should implement when entering the client's room? Elevate the head of the clients bed 13. Select additional instruction(s) the nurse should include in the client's teaching plan. (Select all that apply. One, some, or all options may be correct.) Monitor pulse Do not stop taking prescribed potassium supplements Regular blood draws will be necessary 14. The client has been taking alpha-adrenergic blocker carvedilol 3.125 mg PO twice daily. Which interventions are important for the nurse to include in the client's discharge plan? (Select all that apply. One, some, or all options may be correct.) Avoid abrupt transitions Take with food and restrict salt Do not quickly discontinue the medication Do not take extra medicine 15. The client will be going home on carvedilol 12.5 mg PO twice daily. Choose the most important side effect for the nurse to include in the discharge teaching and document in the electronic medical record (EMR). Slow pulse rate 16. The client is now on furosemide 20 mg PO twice daily. The client is aware that this medication increases urinary output. Which interventions should be included in the client's discharge teaching? (Select all that apply. One, some, or all options may be correct.) Wear sunblock Swollen skin remains indented Report dry mouth 17. What is the most important intervention for the nurse to implement Obtain a serum potassium level 18. Which of the client's serum laboratory values requires intervention by the nurse? Calcium 16mg/dl 19. Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity? Anorexia, nausea, vomiting 20. After treatment with digoxin immune FAB, which of the client's serum laboratory values requires intervention by the nurse? Potassium 3.2 21. Which member of the nursing staff would be best assigned to the client while they are receiving treatment for his digoxin toxicity? An experienced critical care RN who has been assigned to float 22. While applying supplemental oxygen, which intervention is priority for the nurse to initiate? Position patient upright unless contraindicated 23. How would this reading be interpreted by the nurse Respiratory acidosis 24. The client's daughter and the nurse should utilize which source during this decisionmaking process? The clients documented wishes for life saving measures 25. 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? (Select all that apply. One, some, or all options may be correct.) Social worker Clergy person Healthcare providers Extended family 26. The best nursing action in response to this decision would be to? Notify the HCP of the daughters wishes 27. The nurse's best response in this situation would be what? You are going through a very difficult time 28. Choose the best nursing action to implement in response to the daughter's behavior. Stay seated next to daughter and remain quietly attentive 29. Which menu selection by the client indicates that effective teaching has taken place? Fruit snacks to include bananas, oranges, dried apricots 30. In an effort to monitor his heart failure, what is the most important intervention that the client can perform at home? Weighing every day on the same scale Powered by TCPDF (www.tcpdf.org) -