Heart Failure NCLEX Review Q&A Graded A+
The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse
would become concerned with the possibility of digitalis toxicity if the patient reported which
symptom(s)?
A. Muscle aches
B. Constipation
C. ...
Heart Failure NCLEX Review Q&A Graded A+
The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse
would become concerned with the possibility of digitalis toxicity if the patient reported which
symptom(s)?
A. Muscle aches
B. Constipation
C. Pounding headache
D. Anorexia and nausea D. Anorexia and nausea
Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of
digitalis toxicity. The nurse would become concerned and notify the health care provider if the
patient exhibited any of these symptoms.
The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory
results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride
103 mEq/L, and glucose 106 mg/dL. What should the nurse do next?
A. Withhold the daily dose until the following day.
B. Withhold the dose and report the potassium level.
C. Give the digoxin with a salty snack, such as crackers.
D. Give the digoxin with extra fluids to dilute the sodium level. B. Withhold the dose and report
the potassium level.
The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient
more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the
potassium level. The physician may order the digoxin to be given once the potassium level has been
treated and decreases to within normal range.
What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to
treat heart failure?
A. Urine output
B. Lung sounds
, C. Blood pressure
D. Respiratory rate C. Blood pressure
Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority
assessment would be monitoring for hypotension, the main adverse effect of nesiritide.
A patient admitted with heart failure appears very anxious and complains of shortness of breath.
Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)?
A. Administer ordered morphine sulfate.
B. Position patient in a semi-Fowler's position.
C. Position patient on left side with head of bed flat.
D. Instruct patient on the use of relaxation techniques.
E. Use a calm, reassuring approach while talking to patient. A, B, D, E.
Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be
positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation
techniques and a calm reassuring approach will also serve to reduce anxiety.
A male patient with a long-standing history of heart failure has recently qualified for hospice care.
What measure should the nurse now prioritize when providing care for this patient?
A. Taper the patient off his current medications.
B. Continue education for the patient and his family.
C. Pursue experimental therapies or surgical options.
D. Choose interventions to promote comfort and prevent suffering. D. Choose interventions to
promote comfort and prevent suffering.
The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient
education should continue, but providing comfort is paramount. Medications should be continued
unless they are not tolerated. Experimental therapies and surgeries are not commonly used in the
care of hospice patients.
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