Heart Failure with Atrial Fibrillation

Heart failure occurs most commonly in clients over the age of 60, and occurs more commonly in males than females. In addition to these two risk factors, which question will provide the nurse the best data about any additional risk factors for heart failure?
Have you ever had a heart attack?
**Myocardial infarction, coronary artery disease, and ischemic heart disease are among the mot common underlying causes of heart failure. In fact, the most common cause of heart failure is myocardial infarction. The nurse should also ask Bert if he has hypertension, another primary underlying condition causing heart failure.
Which assessment finding would indicate to the nurse that Bert is experiencing right-sided heart failure?
Which cardiac dysrhythmia is Bert most likely experiencing?
Atrial fibrillation
**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.
Based on Bert’s cardiac dysrhythmia, which action should the nurse implement first?
Administer a prescribed stat dose of digoxin (Lanoxin).
**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 Bert’s type of cardiac dysrhythmia.
Of Chest x-ray, 12 lead ECG, echocardiography, and pulmonary artery catheterization, which of these diagnostic tests is used to measure the pressure within the right atrium?
Pulmonary artery catheterization
**pulmonary artery catheters are used in the management of acutely ill clients in the critical care setting. Catheterization allows measurement of the pressures within the right atrium and pulmonary artery, which then guides treatment.

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The nurse prepares a dose of digoxin 0.125mg/IV push. The drug is supplied 0.25mg in 2 mL. How many mL should the nurse prepare to give?
1 mL
Which assessment is most important for the nurse to perform prior to the administration of captopril (Capoten)?
Blood pressure
**Capoten is an angiotensin converting enzyme (ACE) inhibitor used as an anti-hypertensive agent. ACE inhibitors have been shown to prolong survival in clients with heart failure. By lowering the blood pressure (reduced after load), the workload on the heart is reduced. The nurse should monitor Bert’s blood pressure to ensure that the medication is having the desired effect, and that hypotension does not occur.
The nurse explains to Bert that docusate sodium (Colace) has been prescribed for what purpose?
Prevent straining during a bowel movement.
** Colace is a laxative/stool softener that is administered to prevent constipation and straining at stool. A client with cardiac problems should be instructed to avoid use of the Valsalva maneuver (bearing down) to prevent vagal stimulation which may result in bradycardia. The nurse should assess bowel sounds and bowel activity daily to ensure the Colace is effective.
The nurse assesses for which expected outcome of digoxin (Lanolin) therapy?
Serum digoxin level of 1.0 ng/mL.
**The therapeutic level of digoxin is 0.5-2.0 ng/mL. Bert was started on a loading dose of digoxin to reach a therapeutic level as quickly as possible. Levels greater than 2.4 ng/mL are considered toxic. Any client receiving digitalis should be monitored carefully for symptoms of digitalis toxicity.
Which nursing diagnosis should be included in the plan of care?
Impaired gas exchange.
Which intervention should be implemented based on the diagnosis of activity intolerance?
Encourage frequent rest periods.
What action should the nurse implement first?
Elevate the head of Bert’s bed.
**Since the nurse knows that Bert is already experiencing impaired gas exchange and is now obviously dyspneic, the first priority is to reduce the impaired gas exchange. The nurse should first elevate the head of the bed and assist Bert with deep breathing to promote improved oxygenation. Oxygen saturation should be monitored via pulse oximetry, and supplemental oxygen should be provided to maintain adequate oxygenation. Additional assessment includes breath sounds, respiratory rate, rhythm, and effort.
What additional instruction(s) should the nurse include in Bert’s teaching plan? (Select all that apply)
Do not stop taking any prescribed potassium supplements.
**This is especially important if the client is taking a loop diuretic, which causes a loss of potassium. Remember, hypokalemia contributes to digitalis toxicity.
Regular blood draws will be necessary to measure prothrombin time (PT) and INR.
**Bert is taking Coumadin. PT and INR must be monitored regularly to ensure accurate dosing and prevent complications such as bleeding or clotting.
Bert has been taking alpha-adrenergic blocker carvedilol (Coreg) 3.125 mg orally, twice a day. What information is most important for the nurse to provide to Bert?
Avoid abrupt transitions to an erect posture.
**This the most serious adverse response to the alpha-adrenergic blockade. Orthostatic hypotension can reduce blood flow to the brain, thereby causing dizziness, light-headedness, and even syncope.
Bert will be going home on Capoten 12.5 mg orally, twice a day. What information is most important for the nurse to include in the discharge teaching and document in the electronic medical record?
Signs of angioedema.
**The most serious adverse effects of captopril and other ACE inhibitors are angioedema and acute renal failure. Angioedema is manifested by facial, perioral, epiglottal, and/or extremity swelling, intestinal pain, and/or difficulty breathing and may occur at any time during therapy.
Bert is now on Furosemide 20 mg orally, twice a day. Bert is aware that this medication increases his urinary output. He asks then nurse how Lasix helps the heart. What topic information should be included in the nurse’s response?
Reduction of cardiac preload.
**Ventricular fibers contract less forcefully when they are overstretched, such as in a failing heart. Interventions aimed at reducing preload attempt to decrease volume and pressure in the left ventricle, optimizing ventricular muscle stretch and contraction. Common drugs prescribed to reduce preload are diuretics and venous vasodilators. High-ceiling (loop) diuretics, such as furosemide (Lasix) is most effective for treating fluid volume overload.
What is the most important intervention for the nurse to implement?
Obtain a serum potassium level.
**Bert is exhibiting signs of digitalis toxicity and hypokalemia. The nurse should immediately obtain significant lab values, including serum potassium and digitalis levels. Hypokalemia potentiates the effect of digitalis and can result in digitalis toxicity. Serum potassium levels should range between 3.5-5.0 mEq/L. If the potassium value is 3.0 or less, the nurse should withhold the dose of digitalis, and notify the health care provider.
What imbalance places the client taking digoxin (Lasix) at greatest risk of toxicity and associated dysrhythmias?
**Calcium binds with digitalis to decrease the effects of digitalis. In addition, hypercalcemia can cause depressed cardiac activity, dysrhythmias, and cardiac arrest. Along with serum calcium levels, the nurse should also monitor serum magnesium levels. Hypomagnesemia is also a contributing factor to digitalis toxicity, and it can cause dysrhythmias, hypotension, and tachycardia.
Which manifestations are early indications of digitalis toxicity?
Anorexia, nausea, and vomiting.
**GI symptoms are among the earliest symptoms of digitalis toxicity, along with confusion and fatigue. Additional manifestations include headache, hypotension, and cardiac dysrhythmias.
Which electrolyte should be closely monitored in just a few hours after treatment with Digibind?
**A precipitous drop in serum potassium may occur after treatment with Digibind.
Which member of the nursing staff would be best assigned to Bert while he is receiving treatment for his digitalis toxicity?
An experience critical care RN who has been assigned to “float” on the unit.
**This is the best assignment, since Bert requires the assessment skills and clinical judgment abilities of an experienced RN.
During Bert’s treatment with Digibind, the nurse assesses that he is becoming increasingly confused and restless, and that he has developed a frothy, productive cough. Which intervention should the nurse initiate first?
Obtain an oxygen saturation level via pulse oximeter.
**The first priority is to ensure adequate oxygenation. Bert is exhibiting symptoms of pulmonary edema, which results in compromised oxygenation, requiring immediate action by the nurse.
What is the first resource Karen and the nurse should consider during this decision-making process?
Bert’s advance directive.
**A client’s advance directive provides information about the client’s wishes for life-saving procedures and support measures. This is the best resource to help Karen, and the nurse, to determine the course of action that Bert would want if he were able to make a decision at this time.
Karen makes the decision that CPR and mechanical ventilation should not be initiated on her father. What is the best nursing action in response to this decision?
Notify the health care provider of Karen’s wishes.
**DNR orders must be written by the health care provider to be legally binding.
Karen is sitting alone in the dark corner of the room with her arms folded across her chest. She is staring at the blank wall and does not answer the telephone that is ringing next to her. What is the best response by the nurse?
“You are going through a very difficult time.”
**Acknowledging that an individual is going through a difficult experience is an effective therapeutic technique that encourages continued communication.
In response to the nurse’s remark, Karen looks down at the floor, and remains silent. What is the best nursing action in response to Karen’s behavior?
Stay seated next to Karen and remain quietly attentive.
**Silence and offering one’s presence are effective therapeutic techniques to encourage communication.
Which menu selection by Bert indicates that effective teaching has taken place?
Roasted potatoes, fresh green beans, and grilled chicken seasoned with lemon.
**Clients on restricted sodium diets should be encouraged to use seasonings such as lemon, herbs, and garlic instead of salt. Since restricting potassium is not a concern for Bert, the use of a salt substitute (which is high in potassium( can also be included in his diet.
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