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 B

Explanation

The assessment findings of jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute are consistent with right-sided heart failure (HF). Right-sided HF occurs when the right ventricle of the heart is unable to pump effectively, leading to congestion in the venous circulation. This can result in jugular venous distention (JVD) due to increased pressure in the jugular veins, peripheral edema due to fluid retention, and weight gain due to fluid accumulation.

Option A (Left-sided HF) may also present with similar symptoms like jugular venous distention, weight gain, and peripheral edema. However, in left-sided HF, there would typically be signs of pulmonary congestion, such as crackles in the lungs and shortness of breath.

Option C (Chronic heart failure) is a general term used for heart failure that has been present for an extended period, and it does not specify whether it is left-sided or right-sided heart failure.

Option D (Acute decompensated heart failure - ADHF) is a form of heart failure that presents with severe symptoms and requires urgent treatment. It is more of a clinical classification rather than a specific complication related to the symptoms mentioned in the scenario.

A. Potassium B. Calcium C. Iron D. Phosphorous

Correct Answer is ["A","B","D"]

Explanation

A) Potassium: CKD can lead to hyperkalemia (high potassium levels) as the kidneys lose their ability to excrete potassium effectively. Limiting potassium intake helps prevent elevated potassium levels and reduces the risk of cardiac arrhythmias.

B) Calcium: In CKD, impaired kidney function can lead to abnormalities in calcium and phosphorus metabolism, which can result in secondary hyperparathyroidism. Limiting calcium intake can help manage the imbalances in calcium and phosphorus levels.

(D) Phosphorus: Impaired kidney function in CKD leads to decreased phosphate excretion, resulting in hyperphosphatemia (high phosphorus levels). High phosphorus levels can lead to bone disease and other complications, so limiting phosphorus intake is essential.

Iron (C) is not typically limited in the diet of a client with CKD unless they have iron overload or specific conditions that warrant iron restriction.

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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

The assessment findings of a patient with myocardial infarction (MI) include jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute. The nurse suspects what complication?

Correct Answer is B

Explanation

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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The nurse teaches a student nurse about diagnostic studies used for acute coronary syndrome. Which statement made by the student nurse indicates effective learning?

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

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The nurse identifies that a patient with chronic kidney disease is at risk for which electrolyte disturbance?