UNFOLDING REASONING CASE
STUDY HEART FAILURE JOANN
SMITH 72 YEARS ACTUAL
QUESTIONS ANSWERS GRADED
⩥ Which assessment finding provides the earliest indication that the
client is experiencing right-sided heart failure? Answer: Peripheral
edema.
⩥ Based on the electrocardiogram rhythm strip, what intervention
should the nurse implement first? Answer: Obtain a 12 lead ECG.
⩥ After the client's cardiac rhythm is confirmed, which action should the
nurse implement next? Answer: Administer an ordered stat dose of
digoxin.
⩥ When preparing the client for the echocardiogram, which intervention
should the nurse implement? Answer: Ask the client to lay supine during
the test
⩥ The RN charge 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 RN prepare to give? (Enter numeric value only. If rounding is
necessary, round to the whole number.) Answer: 1
, ⩥ After administration of the prescribed captopril, which assessment
finding warrants intervention by the nurse? Answer: Decrease in
baseline blood pressure.
⩥ The nurse is monitoring the client's serum electrolytes. Which of the
client's serum laboratory values requires intervention by the nurse?
Answer: Potassium 3.0 mEq/L (3.0 mmol/L).
⩥ 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? Answer: Monitor INR levels
every 4-6 weeks.
⩥ The nurse observed a family member bringing the client food from
home. Which intervention is most important for the nurse implement?
Answer: Teach the client and his family what foods are low in sodium.
⩥ The client asks the nurse why they have to be weighed every day. The
nurse explains that 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? Answer: Report a gain of 3 pounds in one week.
⩥ What is the first action that the nurse should implement when entering
the client's room? Answer: Elevate the head of the client's bed.
STUDY HEART FAILURE JOANN
SMITH 72 YEARS ACTUAL
QUESTIONS ANSWERS GRADED
⩥ Which assessment finding provides the earliest indication that the
client is experiencing right-sided heart failure? Answer: Peripheral
edema.
⩥ Based on the electrocardiogram rhythm strip, what intervention
should the nurse implement first? Answer: Obtain a 12 lead ECG.
⩥ After the client's cardiac rhythm is confirmed, which action should the
nurse implement next? Answer: Administer an ordered stat dose of
digoxin.
⩥ When preparing the client for the echocardiogram, which intervention
should the nurse implement? Answer: Ask the client to lay supine during
the test
⩥ The RN charge 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 RN prepare to give? (Enter numeric value only. If rounding is
necessary, round to the whole number.) Answer: 1
, ⩥ After administration of the prescribed captopril, which assessment
finding warrants intervention by the nurse? Answer: Decrease in
baseline blood pressure.
⩥ The nurse is monitoring the client's serum electrolytes. Which of the
client's serum laboratory values requires intervention by the nurse?
Answer: Potassium 3.0 mEq/L (3.0 mmol/L).
⩥ 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? Answer: Monitor INR levels
every 4-6 weeks.
⩥ The nurse observed a family member bringing the client food from
home. Which intervention is most important for the nurse implement?
Answer: Teach the client and his family what foods are low in sodium.
⩥ The client asks the nurse why they have to be weighed every day. The
nurse explains that 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? Answer: Report a gain of 3 pounds in one week.
⩥ What is the first action that the nurse should implement when entering
the client's room? Answer: Elevate the head of the client's bed.
