Nokea
The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum?
- A. Skin turgor
- B. Potassium level
- C. White blood cell count
- D. Peripheral pulses
Correct Answer: B
Rationale: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.
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The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first?
- A. Check for a carotid pulse
- B. Apply supplemental oxygen
- C. Give two full breaths
- D. Gently shake and shout, Are you OK?
Correct Answer: D
Rationale: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.
The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with HF. What should the nurse teach this patient about exercise?
- A. Do not exercise unsupervised
- B. Eventually aim to work up to 30 minutes of exercise each day
- C. Slow down if you get dizzy or short of breath
- D. Start your exercise program with high-impact activities
Correct Answer: B
Rationale: Eventually, a total of 30 minutes of physical activity every day should be encouraged. Supervision is not necessarily required and the emergence of symptoms should prompt the patient to stop exercising, not simply to slow the pace. Low-impact activities should be prioritized.
The nurses comprehensive assessment of a patient who has HF includes evaluation of the patients hepatojugular reflux. What action should the nurse perform during this assessment?
- A. Elevate the patients head to 90 degrees
- B. Press the right upper abdomen
- C. Press above the patients symphysis pubis
- D. Lay the patient flat in bed
Correct Answer: B
Rationale: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.
A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurses best action?
- A. Rapidly assess the patients cardiopulmonary status
- B. Arrange for an ECG
- C. Increase the height of the patients bed
- D. Manage the patients anxiety
Correct Answer: A
Rationale: Patient management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the patient, even though each of these actions may be appropriate and necessary.
The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patients care?
- A. Improve functional status
- B. Prevent endocarditis
- C. Extend survival
- D. Limit physical activity
- E. Relieve patient symptoms
Correct Answer: A,C,E
Rationale: The overall goals of management of HF are to relieve the patients symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.