After receiving change-of-shift report on a heart failure unit, which client should the nurse assess first?

Client who is taking digoxin and has a potassium level of 3.1 mEq/L

Client who is taking captopril and has a frequent nonproductive cough

Client who is taking carvedilol (Coreg) and has a heart rate of 58

Client who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache

Answer and Explanation

The Correct Answer is D

The client taking isosorbide dinitrate/hydralazine (BiDil) and experiencing a headache should be assessed first. Isosorbide dinitrate/hydralazine is a medication combination used to treat heart failure, particularly in African American patients. However, one of the side effects of hydralazine is headaches.

Headache in a client taking this medication may indicate increased blood pressure as a compensatory response to vasodilation. If not addressed promptly, it may lead to worsening heart failure or other complications. Therefore, it is essential to assess the client's blood pressure, signs of worsening heart failure, and evaluate the severity and duration of the headache.

The other options may also require attention:

A) A client taking digoxin with a potassium level of 3.1 mEq/L needs assessment, as hypokalemia can increase the risk of digoxin toxicity. However, the headache in the BiDil client takes priority due to the potential complications related to increased blood pressure.

B) A client taking captopril and experiencing a frequent nonproductive cough may indicate a side effect of the medication. While it should be assessed, it is not as immediately concerning as the headache in the BiDil client.

C) A client taking carvedilol (Coreg) with a heart rate of 58 is within an acceptable range, especially if the client is tolerating it well without symptoms. It may not require immediate assessment unless there are other concerning symptoms.

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Correct Answer is A

Explanation

Cloudy peritoneal effluent may indicate infection or peritonitis, which is a severe complication of peritoneal dialysis. Peritonitis can be life-threatening and requires immediate medical attention. The nurse should report this finding promptly to the health care provider for further evaluation and intervention.

A. Permanent pacemakers B. Emergency cardioversion C. IV adenosine (Adenocard) D. Anticoagulant therapy

Correct Answer is D

Explanation

When a patient with dilated cardiomyopathy develops new onset atrial fibrillation (AF) that has been unresponsive to drug therapy, the nurse should prioritize patient education about anticoagulant therapy. Atrial fibrillation increases the risk of blood clots forming in the heart's atria due to the irregular and ineffective pumping of blood. These blood clots can potentially travel to other parts of the body, leading to serious complications such as stroke.

Anticoagulant therapy, also known as blood-thinning medication, is commonly prescribed for patients with atrial fibrillation to prevent the formation of blood clots. The most common anticoagulant prescribed for AF is warfarin or direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, dabigatran, or edoxaban. The nurse should educate the patient about the importance of taking the anticoagulant as prescribed and the need for regular monitoring of clotting times (INR for warfarin) to ensure the medication is effective and the dose is appropriate.

While other options listed in the choices may be relevant in specific situations, the priority in this case is to address the potential risk of stroke associated with atrial fibrillation and the importance of anticoagulant therapy to manage that risk effectively.

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After receiving change-of-shift report on a heart failure unit, which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider?

Correct Answer is A

Explanation

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

Correct Answer is D

Explanation

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