Heart Failure with Atrial
Fibrillation
1. Knowing that the client has two risk factors that cannot be
modified, which intervention is most important for the nurse to
include in the clients plan of care?: Complete a focused cardiac history
assessment.
2. Which assessment finding provides the earliest indication that
the client is experiencing right-sided heart failure?: Peripheral Edema
3. Based on the electrocardiogram rhythm strip, what intervention
should the nurse implement first?: Obtain a 12 lead ECG.
4. After the clients cardiac rhythm is confirmed, which action should
the nurse implement next?: Administer a prescribed stat dose of digoxin.
5. When preparing the client for the echocardiogram, which
intervention should the nurse implement?: Ask the client to lay on their left
side during the test.
6. The 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 nurse prepare to give?: 1 mL
7. After administration of the prescribed captopril, which
assessment finding warrants intervention by the nurse?: Decrease in
baseline blood pressure.
8. The nurse is monitoring the clients serum electrolytes. Which of
the client's serum laboratory values requires intervention by the
nurse?: Potassium 3.0 mEq/L
9. The client is concerned about how easily they are bruising since
they started taking the warfarin. Which intervention is most
important for the nurse to include in the client's plan of care?: Monitor INR
levels every 4-6 weeks.
10. The nurse observed a family member bringing the client food
from home. Which intervention is most important for the nurse to
implement?: Teach the client and his family what foods are low in sodium.
11. The client asks the nurse why they have to be weighed
every day. The nurse explains that the weight gain is one of the
first signs of retaining fluid. Which intervention is most important
for the nurse to include in the client's plan of care?: Report a gain of 3
pounds in one week
1/
5
, Heart Failure with Atrial
Fibrillation
12. What is the first action that the nurse should implement when
entering the client's room?: Elevate the head of the client's bed
13. Select additional instructions the nurse should include in the
client's teach-ing plan. SATA: -Monitor blood pressure prior to administration of digoxin.
2/
5
Fibrillation
1. Knowing that the client has two risk factors that cannot be
modified, which intervention is most important for the nurse to
include in the clients plan of care?: Complete a focused cardiac history
assessment.
2. Which assessment finding provides the earliest indication that
the client is experiencing right-sided heart failure?: Peripheral Edema
3. Based on the electrocardiogram rhythm strip, what intervention
should the nurse implement first?: Obtain a 12 lead ECG.
4. After the clients cardiac rhythm is confirmed, which action should
the nurse implement next?: Administer a prescribed stat dose of digoxin.
5. When preparing the client for the echocardiogram, which
intervention should the nurse implement?: Ask the client to lay on their left
side during the test.
6. The 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 nurse prepare to give?: 1 mL
7. After administration of the prescribed captopril, which
assessment finding warrants intervention by the nurse?: Decrease in
baseline blood pressure.
8. The nurse is monitoring the clients serum electrolytes. Which of
the client's serum laboratory values requires intervention by the
nurse?: Potassium 3.0 mEq/L
9. The client is concerned about how easily they are bruising since
they started taking the warfarin. Which intervention is most
important for the nurse to include in the client's plan of care?: Monitor INR
levels every 4-6 weeks.
10. The nurse observed a family member bringing the client food
from home. Which intervention is most important for the nurse to
implement?: Teach the client and his family what foods are low in sodium.
11. The client asks the nurse why they have to be weighed
every day. The nurse explains that the weight gain is one of the
first signs of retaining fluid. Which intervention is most important
for the nurse to include in the client's plan of care?: Report a gain of 3
pounds in one week
1/
5
, Heart Failure with Atrial
Fibrillation
12. What is the first action that the nurse should implement when
entering the client's room?: Elevate the head of the client's bed
13. Select additional instructions the nurse should include in the
client's teach-ing plan. SATA: -Monitor blood pressure prior to administration of digoxin.
2/
5
