HESI Case Studies-Heart Failure with Atrial Fibrillation (Bert Graham)
1. 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?”
2. Which assessment finding would indicate to the nurse that Bert is experiencing right-sided heart failure?
3. Which cardiac dysrhythmia is Bert most likely experiencing?
4. Based on Bert’s cardiac dysrhythmia, which action should the nurse implement first?
Administer a prescribed stat dose of digoxin (Lanoxin)
5. Which of these diagnostic tests is used to measure the pressure within the right atrium?
Pulmonary artery catheterization
6. The nurse prepares a dose of digoxin (Lanoxin) 0.125 mg/IV push. The drug is supplied 0.25 mg in 2 mL. How many mL should the nurse prepare to give?
7. Which assessment is most important for the nurse to perform prior to the administration of captopril (Capoten)?
8. The nurse explains to Bert that docusate sodium (Colace) has been prescribed for what purpose?
prevent straining during a bowel movement
9. The nurse assesses for which expected outcome of digoxin (Lanoxin) therapy
Serum digoxin level of 1.0 ng/ml
10. Which nursing diagnosis should be included in the plan of care?
Impaired gas exchange
11. Which intervention should be implemented based on the diagnosis of activity intolerance?
Encourage frequent rest periods
12. Which action should the nurse implement first?
Elevate the head of Bert’s bed
13. 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
-Regular blood draws will be necessary to measure prothrombin time (PT) and INR
14. 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 and erect posture
15. 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 (EMR)?
Signs of angioedema
16. Bert is now on Furosemide (Lasix) 20 mg orally, twice a day. Bert is aware that this medication increases his urinary output. He asks the nurse how Lasix helps his heart. What topic information should be included in the nurse’s response?
Reduction of cardiac preload
17. What is the most important intervention for the nurse to implement?
Obtain a serum potassium level
18. What imbalance places the client taking digoxin (Lanoxin) at greatest risk of toxicity and associated dysrhythmias?
19. Which manifestations are early indications of digoxin toxicity?
Anorexia, nausea, vomiting
20. Which electrolyte should be closely monitored in just a few hours after treatment with Digibind?
21. Which member of the nursing staff would be best assigned to Bert while he is receiving treatment for his digitalis toxicity?
An experienced critical care RN who has been assigned to “float” on the unit
22. Which intervention should the nurse initiate first?
Obtain an oxygen saturation level via pulse oximeter
23. What is the first resource Karen and the nurse should consider during this decision-making process?
Bert’s advance directive
24. What is the best nursing action in response to the decision?
Notify the health care provider of Karen’s wishes
25. What is the best response by the nurse?
“You are going through a very difficult time.”
26. What is the best nursing action in response to Karen’s behavior?
Stay seated next to Karen and remain quietly attentive
27. Which menu selection by Bert indicates that effective teaching has taken place?
Roasted potatoes, fresh green beans, and grilled chicken seasoned with lemon