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The nurse is providing patient education prior to a patients discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist?
- A. Know how to recognize and prevent orthostatic hypotension
- B. Weigh yourself weekly at a consistent time of day
- C. Measure everything you eat and drink until otherwise instructed
- D. Limit physical activity to only those tasks that are absolutely necessary
Correct Answer: A
Rationale: Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.
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A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurses nutritional teaching plan has been effective?
- A. I will have a ham and cheese sandwich for lunch
- B. I will have a baked potato with broiled chicken for dinner
- C. I will have a tossed salad with cheese and croutons for lunch
- D. I will have chicken noodle soup with crackers and an apple for lunch
Correct Answer: B
Rationale: The patients choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.
A patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patients health history creates a heightened risk of intracardiac thrombi?
- A. Atrial fibrillation
- B. Infective endocarditis
- C. Recurrent pneumonia
- D. Recent surgery
Correct Answer: A
Rationale: Intracardiac thrombi are especially common in patients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.
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.
Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?
- A. Monitor liver function studies
- B. Monitor for hypotension
- C. Assess the patients vitamin D intake
- D. Assess the patient for hyperkalemia
Correct Answer: B
Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.
The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms?
- A. Confusion and bradycardia
- B. Uncontrolled diuresis and tachycardia
- C. Numbness and tingling in the extremities
- D. Chest pain and shortness of breath
Correct Answer: A
Rationale: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.