HESI Case Studies-Heart Failure with Atrial Fibrillation (Bert Graham) – Flashcards
Unlock all answers in this set
Unlock answersquestion
1. In addition to these two risk factors, which question will provide the nurse the best data about any additional risk factors for heart failure?
answer
"Have you ever had a heart attack?"
question
2. Which assessment finding would indicate to the nurse that Bert is experiencing right-sided heart failure?
answer
Edema
question
3. Which cardiac dysrhythmia is Bert most likely experiencing?
answer
Atrial fibrillation
question
4. Based on Bert's cardiac dysrhythmia, which action should the nurse implement first?
answer
Administer a prescribed stat dose of digoxin (Lanoxin)
question
5. Which of these diagnostic tests is used to measure the pressure within the right atrium?
answer
Pulmonary artery catheterization
question
6. The nurse prepares a dose of digoxin (Lanoxin) 0.125 mg/IV push. The drug is supplied 0.25 mg in 2 mL. How many mL should the nurse prepare to give?
answer
1
question
7. Which assessment is most important for the nurse to perform prior to the administration of captopril (Capoten)?
answer
Blood pressure
question
8. The nurse explains to Bert that docusate sodium (Colace) has been prescribed for what purpose?
answer
prevent straining during a bowel movement
question
9. The nurse assesses for which expected outcome of digoxin (Lanoxin) therapy
answer
Serum digoxin level of 1.0 ng/ml
question
10. Which nursing diagnosis should be included in the plan of care?
answer
Impaired gas exchange
question
11. Which intervention should be implemented based on the diagnosis of activity intolerance?
answer
Encourage frequent rest periods
question
12. Which action should the nurse implement first?
answer
Elevate the head of Bert's bed
question
13. What additional instruction(s) should the nurse include in Bert's teaching plan? Select all that apply
answer
-Do not stop taking any prescribed potassium supplements -Regular blood draws will be necessary to measure prothrombin time (PT) and INR
question
14. Bert has been taking alpha-adrenergic blocker carvedilol (Coreg) 3.125 mg orally, twice a day. What information is most important for the nurse to provide to Bert?
answer
Avoid abrupt transitions to and erect posture
question
15. Bert will be going home on Capoten 12.5 mg orally, twice a day. What information is most important for the nurse to include in the discharge teaching and document in the electronic medical record (EMR)?
answer
Signs of angioedema
question
16. Bert is now on Furosemide (Lasix) 20 mg orally, twice a day. Bert is aware that this medication increases his urinary output. He asks the nurse how Lasix helps his heart. What topic information should be included in the nurse's response?
answer
Reduction of cardiac preload
question
17. What is the most important intervention for the nurse to implement?
answer
Obtain a serum potassium level
question
18. What imbalance places the client taking digoxin (Lanoxin) at greatest risk of toxicity and associated dysrhythmias?
answer
Hypercalcemia
question
19. Which manifestations are early indications of digoxin toxicity?
answer
Anorexia, nausea, vomiting
question
20. Which electrolyte should be closely monitored in just a few hours after treatment with Digibind?
answer
Potassium
question
21. Which member of the nursing staff would be best assigned to Bert while he is receiving treatment for his digitalis toxicity?
answer
An experienced critical care RN who has been assigned to "float" on the unit
question
22. Which intervention should the nurse initiate first?
answer
Obtain an oxygen saturation level via pulse oximeter
question
23. What is the first resource Karen and the nurse should consider during this decision-making process?
answer
Bert's advance directive
question
24. What is the best nursing action in response to the decision?
answer
Notify the health care provider of Karen's wishes
question
25. What is the best response by the nurse?
answer
"You are going through a very difficult time."
question
26. What is the best nursing action in response to Karen's behavior?
answer
Stay seated next to Karen and remain quietly attentive
question
27. Which menu selection by Bert indicates that effective teaching has taken place?
answer
Roasted potatoes, fresh green beans, and grilled chicken seasoned with lemon
