Heart Failure NCLEX Questions and Answers and
Rationale New Update (Verified Version 2025)
A client with congestive heart failure, CHF, is prescribed digoxin (Lanoxin) and
furosemide (Lasix). Nursing interventions will include: (Select all that apply.)
Encourage intake of water and fruit juices.
Restrict intake of green, leafy vegetables.
Checking apical pulse before administering medication.
Monitor hemoglobin and hematocrit levels.
Monitor serum electrolytes. - ans -Checking apical pulse before administering
medication.
Monitor serum electrolytes.
Rationale: Digoxin is a cardiac glycoside. which can slow heart rate, and an apical
heart rate is checked prior to administration. Lasix is a loop diuretic used in
treatment of CHF, which promotes not only water loss, but also loss of
electrolytes. A low potassium level increases risk 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.
The client is prescribed digoxin (Lanoxin) for treatment of HR. Which of the
following statements by the client indicates the need for further teaching by the
nurse?
"I should not get short of breath anymore."
"This drug will help my heart muscle pump less."
"I may notice my heart rate decrease."
"I may feel tired during early treatment." - ans -"This drug will help my heart
muscle pump less."
Rationale: The ability to increase the strength of contractions is a characteristic of
cardiac glycosides. It may result in a decrease in pulse. Initially the client may
experience some fatigue. Symptoms of CHF, such as dyspnea, should improve.
, The nurse reviews lab studies of a client receiving digoxin (Lanoxin). Intervention
by the nurse is required if the results include a
Serum sodium level of 140 mEq/L.
Serum digoxin level of 1.2 ng/dL.
Serum potassium level of 3.0 mEq/L.
Hemoglobin 14.4 g/dL. - ans -Serum potassium level of 3.0 mEq/L.
Rationale: Normal serum potassium level is 3.5-5.0 mEq/L. Hypokalemia may
predispose the client to digitalis toxicity. The other lab values are WNL.
The client's serum digoxin level is 2.2 ng/dL and the heart rate is 120 and
irregular. The nurse expects to administer which of the following drugs?
Digoxin immune Fab (Digibind)
Furosemide (Lasix) 60 mg I.V.
Digoxin 0.5 mg bolus I.V.
Potassium 40 mEq added to I.V. fluids - ans -Digoxin immune Fab (Digibind)
Rationale: Digibind binds and removes digoxin from the body and prevents toxic
effects of digoxin overdose. A serum level of 2.2 is elevated, and the client is
exhibiting signs of digoxin toxicity. The question does not indicate that the
potassium level is low. Giving additional digoxin would exacerbate the toxicity.
Giving Lasix may reduce potassium levels and contribute to increased toxicity.
The client is prescribed captopril (Capoten) for treatment of HF. The nurse
teaches that the primary action of the drug is to
Prevent influx of calcium.
Lower peripheral resistance and reduce blood volume.
Increase strength of ventricular contractions.
Increase heart rate. - ans -Lower peripheral resistance and reduce blood volume.
Rationale: ACE inhibitors decrease peripheral resistance and reduce blood volume
by enhancing the excretion of sodium and water. This results in decreased
afterload and increased cardiac output.
Rationale New Update (Verified Version 2025)
A client with congestive heart failure, CHF, is prescribed digoxin (Lanoxin) and
furosemide (Lasix). Nursing interventions will include: (Select all that apply.)
Encourage intake of water and fruit juices.
Restrict intake of green, leafy vegetables.
Checking apical pulse before administering medication.
Monitor hemoglobin and hematocrit levels.
Monitor serum electrolytes. - ans -Checking apical pulse before administering
medication.
Monitor serum electrolytes.
Rationale: Digoxin is a cardiac glycoside. which can slow heart rate, and an apical
heart rate is checked prior to administration. Lasix is a loop diuretic used in
treatment of CHF, which promotes not only water loss, but also loss of
electrolytes. A low potassium level increases risk 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.
The client is prescribed digoxin (Lanoxin) for treatment of HR. Which of the
following statements by the client indicates the need for further teaching by the
nurse?
"I should not get short of breath anymore."
"This drug will help my heart muscle pump less."
"I may notice my heart rate decrease."
"I may feel tired during early treatment." - ans -"This drug will help my heart
muscle pump less."
Rationale: The ability to increase the strength of contractions is a characteristic of
cardiac glycosides. It may result in a decrease in pulse. Initially the client may
experience some fatigue. Symptoms of CHF, such as dyspnea, should improve.
, The nurse reviews lab studies of a client receiving digoxin (Lanoxin). Intervention
by the nurse is required if the results include a
Serum sodium level of 140 mEq/L.
Serum digoxin level of 1.2 ng/dL.
Serum potassium level of 3.0 mEq/L.
Hemoglobin 14.4 g/dL. - ans -Serum potassium level of 3.0 mEq/L.
Rationale: Normal serum potassium level is 3.5-5.0 mEq/L. Hypokalemia may
predispose the client to digitalis toxicity. The other lab values are WNL.
The client's serum digoxin level is 2.2 ng/dL and the heart rate is 120 and
irregular. The nurse expects to administer which of the following drugs?
Digoxin immune Fab (Digibind)
Furosemide (Lasix) 60 mg I.V.
Digoxin 0.5 mg bolus I.V.
Potassium 40 mEq added to I.V. fluids - ans -Digoxin immune Fab (Digibind)
Rationale: Digibind binds and removes digoxin from the body and prevents toxic
effects of digoxin overdose. A serum level of 2.2 is elevated, and the client is
exhibiting signs of digoxin toxicity. The question does not indicate that the
potassium level is low. Giving additional digoxin would exacerbate the toxicity.
Giving Lasix may reduce potassium levels and contribute to increased toxicity.
The client is prescribed captopril (Capoten) for treatment of HF. The nurse
teaches that the primary action of the drug is to
Prevent influx of calcium.
Lower peripheral resistance and reduce blood volume.
Increase strength of ventricular contractions.
Increase heart rate. - ans -Lower peripheral resistance and reduce blood volume.
Rationale: ACE inhibitors decrease peripheral resistance and reduce blood volume
by enhancing the excretion of sodium and water. This results in decreased
afterload and increased cardiac output.
