ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 28 : Caring for Clients With Heart Failure Questions
Question 1 of 5
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?
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.
Question 2 of 5
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?
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.
Question 3 of 5
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?
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.
Question 4 of 5
A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?
Correct Answer: D
Rationale: VADs may be used for one of three purposes: (1) a bridge to recovery, (2) a bridge to transport, or (3) destination therapy (mechanical circulatory support when there is no option for a heart transplant). An implanted cardioverter-defibrillator or pacemaker is not a bridge to transplant and will only correct the conduction disturbance and not the pumping efficiency. An IABP is a temporary, secondary mechanical circulatory pump to supplement the ineffectual contraction of the left ventricle. The IABP is intended for only a few days.
Question 5 of 5
A client with heart failure reports not having had a bowel movement in 2 days. Why would it be important for the nurse to obtain a prescription for a stool softener?
Correct Answer: A
Rationale: Avoid activities that engage the Valsalva maneuver, such as straining with bowel elimination or using the arms to pull and reposition oneself. The Valsalva maneuver increases intrathoracic pressure, reduces right atrial filling, triggers tachycardia, and increases blood pressure. The client's discomfort would be increased if hemorrhoids or a rectal fissure developed but would not engage the Valsalva maneuver. It is not necessary for the client to have a bowel movement on a daily basis.