HEART FAILURE NCLEX EXAM 3 LATEST VERSIONS (VERSION A, B A
C) 2024 ACTUAL EXAM 100 QUESTIONS AND CORRECT DETAILED AN
SWERS WITH RATIONALES
Study online at https://quizlet.com/_flwmzx
1. A client with congestive heart failure, Checking apical pulse before ad-
CHF, is prescribed digoxin (Lanoxin) ministering medication.
and furosemide (Lasix). Nursing inter-
ventions will include: (Select all that Monitor serum electrolytes.
apply.)
Encourage intake of water and fruit Rationale: Digoxin is a cardiac gly-
juices. coside. which can slow heart rate,
Restrict intake of green, leafy vegeta- and an apical heart rate is checked
bles. prior to administration. Lasix is a
Checking apical pulse before admin- loop diuretic used in treatment of
istering medication. CHF, which promotes not only water
Monitor hemoglobin and hematocrit loss, but also loss of electrolytes. A
levels. low potassium level increases risk
Monitor serum electrolytes. of digoxin toxicity. Fluids are often
restricted with CHF. H and H level do
not need to be checked, and green,
leafy vegetables would not need to
be restricted.
2. The client is prescribed digoxin "This drug will help my heart muscle
(Lanoxin) for treatment of HR. Which pump less."
of the following statements by the
client indicates the need for further Rationale: The ability to increase the
teaching by the nurse? strength of contractions is a charac-
teristic of cardiac glycosides. It may
"I should not get short of breath any- result in a decrease in pulse. Initial-
more." ly the client may experience some
"This drug will help my heart muscle fatigue. Symptoms of CHF, such as
pump less." dyspnea, should improve.
"I may notice my heart rate de-
crease."
"I may feel tired during early treat-
ment."
3. The nurse reviews lab studies of a Serum potassium level of 3.0
client receiving digoxin (Lanoxin). In- mEq/L.
tervention by the nurse is required if
1/6
, HEART FAILURE NCLEX EXAM 3 LATEST VERSIONS (VERSION A, B A
C) 2024 ACTUAL EXAM 100 QUESTIONS AND CORRECT DETAILED AN
SWERS WITH RATIONALES
Study online at https://quizlet.com/_flwmzx
the results include a Rationale: Normal serum potassium
level is 3.5-5.0 mEq/L. Hypokalemia
Serum sodium level of 140 mEq/L. may predispose the client to digital-
Serum digoxin level of 1.2 ng/dL. is toxicity. The other lab values are
Serum potassium level of 3.0 mEq/L. WNL.
Hemoglobin 14.4 g/dL.
4. The client's serum digoxin level is 2.2 Digoxin immune Fab (Digibind)
ng/dL and the heart rate is 120 and
irregular. The nurse expects to admin- Rationale: Digibind binds and re-
ister which of the following drugs? moves digoxin from the body and
prevents toxic effects of digoxin
Digoxin immune Fab (Digibind) overdose. A serum level of 2.2 is
Furosemide (Lasix) 60 mg I.V. elevated, and the client is exhibiting
Digoxin 0.5 mg bolus I.V. signs of digoxin toxicity. The ques-
Potassium 40 mEq added to I.V. fluids tion does not indicate that the potas-
sium level is low. Giving additional
digoxin would exacerbate the toxic-
ity. Giving Lasix may reduce potas-
sium levels and contribute to in-
creased toxicity.
5. The client is prescribed captopril Lower peripheral resistance and re-
(Capoten) for treatment of HF. The duce blood volume.
nurse teaches that the primary action
of the drug is to Rationale: ACE inhibitors decrease
peripheral resistance and reduce
Prevent influx of calcium. blood volume by enhancing the ex-
Lower peripheral resistance and re- cretion of sodium and water. This
duce blood volume. results in decreased afterload and
Increase strength of ventricular con- increased cardiac output.
tractions.
Increase heart rate.
6. A client is being started on lisinopril Monitoring blood pressure.
(Zestril). Nursing interventions during
initial therapy with this medication Rationale: Lisinopril is an ACE in-
must include hibitor, which can cause severe hy-
2/6
C) 2024 ACTUAL EXAM 100 QUESTIONS AND CORRECT DETAILED AN
SWERS WITH RATIONALES
Study online at https://quizlet.com/_flwmzx
1. A client with congestive heart failure, Checking apical pulse before ad-
CHF, is prescribed digoxin (Lanoxin) ministering medication.
and furosemide (Lasix). Nursing inter-
ventions will include: (Select all that Monitor serum electrolytes.
apply.)
Encourage intake of water and fruit Rationale: Digoxin is a cardiac gly-
juices. coside. which can slow heart rate,
Restrict intake of green, leafy vegeta- and an apical heart rate is checked
bles. prior to administration. Lasix is a
Checking apical pulse before admin- loop diuretic used in treatment of
istering medication. CHF, which promotes not only water
Monitor hemoglobin and hematocrit loss, but also loss of electrolytes. A
levels. low potassium level increases risk
Monitor serum electrolytes. of digoxin toxicity. Fluids are often
restricted with CHF. H and H level do
not need to be checked, and green,
leafy vegetables would not need to
be restricted.
2. The client is prescribed digoxin "This drug will help my heart muscle
(Lanoxin) for treatment of HR. Which pump less."
of the following statements by the
client indicates the need for further Rationale: The ability to increase the
teaching by the nurse? strength of contractions is a charac-
teristic of cardiac glycosides. It may
"I should not get short of breath any- result in a decrease in pulse. Initial-
more." ly the client may experience some
"This drug will help my heart muscle fatigue. Symptoms of CHF, such as
pump less." dyspnea, should improve.
"I may notice my heart rate de-
crease."
"I may feel tired during early treat-
ment."
3. The nurse reviews lab studies of a Serum potassium level of 3.0
client receiving digoxin (Lanoxin). In- mEq/L.
tervention by the nurse is required if
1/6
, HEART FAILURE NCLEX EXAM 3 LATEST VERSIONS (VERSION A, B A
C) 2024 ACTUAL EXAM 100 QUESTIONS AND CORRECT DETAILED AN
SWERS WITH RATIONALES
Study online at https://quizlet.com/_flwmzx
the results include a Rationale: Normal serum potassium
level is 3.5-5.0 mEq/L. Hypokalemia
Serum sodium level of 140 mEq/L. may predispose the client to digital-
Serum digoxin level of 1.2 ng/dL. is toxicity. The other lab values are
Serum potassium level of 3.0 mEq/L. WNL.
Hemoglobin 14.4 g/dL.
4. The client's serum digoxin level is 2.2 Digoxin immune Fab (Digibind)
ng/dL and the heart rate is 120 and
irregular. The nurse expects to admin- Rationale: Digibind binds and re-
ister which of the following drugs? moves digoxin from the body and
prevents toxic effects of digoxin
Digoxin immune Fab (Digibind) overdose. A serum level of 2.2 is
Furosemide (Lasix) 60 mg I.V. elevated, and the client is exhibiting
Digoxin 0.5 mg bolus I.V. signs of digoxin toxicity. The ques-
Potassium 40 mEq added to I.V. fluids tion does not indicate that the potas-
sium level is low. Giving additional
digoxin would exacerbate the toxic-
ity. Giving Lasix may reduce potas-
sium levels and contribute to in-
creased toxicity.
5. The client is prescribed captopril Lower peripheral resistance and re-
(Capoten) for treatment of HF. The duce blood volume.
nurse teaches that the primary action
of the drug is to Rationale: ACE inhibitors decrease
peripheral resistance and reduce
Prevent influx of calcium. blood volume by enhancing the ex-
Lower peripheral resistance and re- cretion of sodium and water. This
duce blood volume. results in decreased afterload and
Increase strength of ventricular con- increased cardiac output.
tractions.
Increase heart rate.
6. A client is being started on lisinopril Monitoring blood pressure.
(Zestril). Nursing interventions during
initial therapy with this medication Rationale: Lisinopril is an ACE in-
must include hibitor, which can cause severe hy-
2/6
