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A client has been admitted to a health care center with complaints of dyspnea. The nurse suspects left-sided heart failure based on assessment of which of the following?
- A. Nocturia
- B. Pitting edema
- C. Weight gain
- D. Orthopnea
Correct Answer: D
Rationale: The nurse should assess for orthopnea in clients with left-sided heart failure. Orthopnea is a condition where the client experiences difficulty in breathing on lying down. The other features of left ventricular failure include a hacking cough or wheezing, restlessness, and anxiety. Nocturia, pitting edema, and weight gain are associated with right-sided heart failure.
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The nurse should educate the client to avoid which of the following nonprescription medications without permission from the physician, as they can interfere with the action of cardiotonic drugs? Select all that apply.
- A. Antacids
- B. Antidiarrheals
- C. Topical arthritis treatments
- D. Artificial tear products
- E. Allergy products
Correct Answer: A,B,E
Rationale: The nurse should teach the client to avoid antacids and nonprescription cough, cold, allergy, antidiarrheal, and diet drugs unless their use has been approved by the physician, as some of these drugs interfere with the action of cardiotonic drugs or cause other potentially serious problems.
A client is prescribed droxin IV as a loading dose. The nurse would expect to administer the drug over which time frame?
- A. 30 seconds
- B. 2 minutes
- C. 5 minutes
- D. 30 minutes
Correct Answer: C
Rationale: When a cardiotonic drug is given IV, it is administered slowly (over at least 5 minutes), and the administration site is assessed for redness or infiltration.
A client comes to the clinic for a visit. The client has been taking digoxin for several months. While interviewing the client, the nurse suspects the client is experiencing digoxin toxicity based on which of the following? Select all that apply.
- A. Anorexia
- B. Weakness
- C. Inability to relax
- D. Photosensitivity
- E. Disorientation
Correct Answer: A,B,E
Rationale: Signs of digitalis toxicity include anorexia, weakness, lethargy, blurred vision, and disorientation. An inability to relax and photosensitivity are not associated with digitalis toxicity.
When educating a group of nursing students on the signs of heart failure, the nurse mentions that the ejection fraction is altered in heart failure. The students demonstrate understanding of the information when they identify which ejection fraction as suggesting heart failure?
- A. 38%
- B. 48%
- C. 58%
- D. 68%
Correct Answer: A
Rationale: The ejection fraction is the amount of blood that is ejected from the ventricles per beat in relation to the amount of blood available to eject. An ejection fraction of less than 40% indicates heart failure. Normally the ejection fraction should be greater than 60%.
A nurse checks the serum digoxin level of a client and finds it to be increased. Which of the following would the nurse identify as possibly associated with this increase?
- A. Colestipol (Colestid)
- B. Verapamil (Calan)
- C. Clarithromycin (Biaxin)
- D. Calcium carbonate (Maalox)
- E. Spironolactone (Aldactone)
Correct Answer: B,C,E
Rationale: Increased serum digoxin levels can occur with verapamil, clarithromycin, and spironolactone. Antacids, such as calcium carbonate, and colestipol cause a decrease in serum digoxin levels.