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The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?
- A. Administer the medication and inform the charge nurse about the rate.
- B. Withhold the medication and notify the health care provider of the heart rate.
- C. Administer atropine to speed the heart rate and then administer the digoxin.
- D. Administer the medications and then notify the health care provider.
Correct Answer: B
Rationale: Digitalis drugs are withheld if the heart rate is less than 60 or more than 120 beats/minute until a health care provider is consulted. The other choices would have the nurse administer the drug, which would not be the standard of practice.
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The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?
- A. Low-fat diet
- B. Low-potassium diet
- C. Low-cholesterol diet
- D. Low-sodium diet
Correct Answer: D
Rationale: Medical management of both left-sided and right-sided heart failure is directed at reducing the heart's workload and improving cardiac output primarily through dietary modifications, drug therapy, and lifestyle changes. A low-sodium diet is prescribed, and fluids may be restricted. Because the client will be on a diuretic such as Lasix, he may become potassium depleted and would need potassium in the diet. A low-cholesterol and low-fat diet may be prescribed but are not specific to the heart failure.
The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide?
- A. BNP of 100
- B. Sodium level of 135
- C. Hemoglobin of 12
- D. Potassium level of 3.1
Correct Answer: D
Rationale: Severe heart failure usually requires a loop diuretic such as furosemide (Lasix). These drugs increase sodium and therefore water excretion, but they also increase potassium excretion. If a client becomes hypokalemic, digitalis toxicity is more likely. The BNP does not demonstrate a severe heart failure. Sodium level of 135 is within normal range, as is the hemoglobin level.
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, 'I cannot catch my breath.' How would the nurse document this finding?
- A. Can't walk without becoming short of breath
- B. Has paroxysmal nocturnal dyspnea when walking
- C. Has orthopnea when walking
- D. Experiences exertional dyspnea when walking 3 feet; states, I cannot catch my breath.
Correct Answer: D
Rationale: Exertional dyspnea is the effort at breathing when active. Answer A is vague and does not give a more detailed explanation for documentation purposes. Orthopnea is the inability to breathe unless sitting upright, and paroxysmal nocturnal dyspnea is being awakened by breathlessness.
A client is admitted to the hospital with a diagnosis of heart failure, and the health care provider prescribes a BNP level. What results would indicate to the nurse that the client is in moderate heart failure?
- A. 120 pg/mL
- B. 400 pg/mL
- C. 780 pg/mL
- D. 980 pg/mL
Correct Answer: C
Rationale: The result of 780 pg/mL indicates that the client has moderate heart failure, 120 pg/mL indicates that the client has heart failure present, 400 pg/mL indicates that the client has mild heart failure, and 980 pg/mL indicates that the client is in severe heart failure.
The nurse is administering captopril to a client with a diagnosis of heart failure. What type of medication does the nurse infer the client is taking?
- A. An angiotensin converting enzyme inhibitor (ACE) inhibitor
- B. A thiazide diuretic
- C. An angiotensin receptor blocker (ARB)
- D. A calcium channel blocker
Correct Answer: A
Rationale: Captopril is an ACE inhibitor. Although the other medications may be used alone or in conjunction with other medications, the ACE inhibitor is a standard medication used in heart failure unless not tolerated by the client.