Exam (elaborations)
Heart Failure with Atrial Fibrillation-Case Study.
Heart Failure with Atrial Fibrillation-Case Study.
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Heart Failure with Atrial Fibrillation-CaseStudy
Knowing that the client has two risk factors that cannot be modified, which intervention
is most important for the nurse to include in the client's plan of care? - ✔Complete a
focused cardiac history assessment.
--Myocardial infarction, coronary artery disease, and ischemic heart disease are among
the most common underlying causes of heart failure. In fact, the most common cause of
heart failure is myocardial infarction. The nurse should also ask the client if they have
hypertension which is another primary underlying condition causing heart failure
Right-sided, or right ventricular, heart failure often occurs due to left-sided heart failure
when the weakened or stiff left ventricle cannot efficiently pump blood to the rest of the
body. As a result, fluid is forced back through the lungs, weakening the heart's right
side, causing right-sided heart failure.
Which assessment finding provides the earliest indication that the client is experiencing
right-sided heart failure? - ✔Peripheral edema
--Right-sided heart failure results in peripheral congestion due to the inability of the right
ventricle to effectively pump blood out of the heart to the lungs, causing edema, JVD, an
enlarged liver, abdominal ascites, and weight gain. Edema and weight gain are among
the earlier signs.
Upon admission to the Cardiac Nursing Unit, the client's dyspnea continues. The client
reports fatigue, but denies chest pain. The nurse places the client on oxygen via a nasal
cannula at 3 L/min and a cardiac telemetry monitor. The ECG recording shows no
discernible P waves, and a rapid, irregular ventricular response (QRS complexes). This
corresponds with the client's pulse rate, which is 136 and irregular.
Based on the electrocardiogram rhythm strip, what intervention should the nurse
implement first? - ✔Obtain a 12 lead ECG.
-A 12 lead should be performed immediately to confirm the rhythm and determine if
there is any acute myocardial injury occuring. Atrial fibrillation commonly occurs in heart
failure. Multiple areas in the atria initiate rapid, irregular electrical stimuli, which results
in the inability to see clear P waves on the ECG recording. Some, but not all, of these
electrical impulses travel through the AV node, causing an irregular ventricular
response. This appears as irregular QRS complexes on the ECG recording and
manifests as an irregular pulse rhythm when assessing the client.
, After the client's cardiac rhythm is confirmed, which action should the nurse implement
next? - ✔Administer an ordered stat dose of digoxin
-If a dose of digoxin has already been prescribed, it should be administered before
taking further action. Digoxin slows the heart rate and increases the force of the heart's
contraction, which is very useful in the treatment of the client's type of cardiac
dysrhythmia.
The client is scheduled for a chest x-ray, 12 lead electrocardiograph (ECG) and an
echocardiogram.
When preparing the client for the echocardiogram, which intervention should the nurse
implement? - ✔Ask the client to lay supine during the test
-The echocardiogram records direction and flow of blood through the heart and
transforms it to audio and graphic data that measure valve abnormalities, congenital
heart defects, wall motion, ejection fraction (EF), and heart function. The best results
are obtained when the patient is in the supine position. The technician may also request
the client to lay on their left side.
The RN charge nurse prepares a dose of digoxin 0.125 mg IV push. The medication is
supplied as 0.25 mg in 2 mL. How many mL should the RN prepare to give? (Enter
numeric value only. If rounding is necessary, round to the whole number.) - ✔1 mL
After administration of the prescribed captopril, which assessment finding warrants
intervention by the nurse? - ✔Decrease in baseline blood pressure
--Captopril is an angiotensin converting enzyme (ACE) inhibitor used as an
antihypertensive agent. ACE inhibitors have been shown to prolong survival in clients
with heart failure. By lowering the blood pressure (reduced afterload), the workload on
the heart is reduced. The nurse should monitor the client's blood pressure to ensure that
the medication is having the desired effect, and that hypotension does not occur.
Excessive hypotension and hyperkalemia may occur. Monitor the client for first-dose
hypotension (first-dose syncope).
The nurse is monitoring the client's serum electrolytes. Which of the client's serum
laboratory values requires intervention by the nurse? - ✔Potassium 3.0 mEq/L (3.0
mmol/L)
--Normal potassium is 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L). The diuretic (furosemide)
decreases sodium reabsorption which enhances sodium and water loss putting the
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