Case Study:

Heart Failure with Atrial Fibrillation

36 Questions & Answers with Rationale
Case Study – Question 1
Mr. Jonathan Peters just celebrated his 65 birthday on the weekend followed
by an official retirement as a heavy equipment operator for a local
construction company. Jonathan visits the healthcare clinic complaining of
increasing fatigue and difficulty breathing. Initial vitals include a rapid,
irregular radial pulse of 138/min, BP 140/86, RR 28/min. He has a history of
coronary artery disease. What action should the nurse take to confirm the
heart rate?

A. Palpate both radial pulses simultaneously

B. Auscultate the apical pulse for one minute
C. Compare the ulnar pulse to the radial pulse
D. Ask the client if he experiences palpitations
Case Study – Answer 1

A. Palpate both radial pulses simultaneously

• Not the best method to confirm the HR with irregular cardiac rhythm

B. Auscultate the apical pulse for one minute

• Most accurate method to determine HR and rhythm through auscultation at the
PMI, rather than depending on palpation of transmitted pulse to a distal site

C. Compare the ulnar pulse to the radial pulse

• Ulnar pulse if often difficult to palpate and not the best site to assess cardiac rate
and rhythm

D. Ask the client if he experiences palpitations

• Does not provide data that will confirm the client’s heart rate. Palpitations may
occur with either a regular or irregular cardiac rhythm
Case Study - Update

Further assessment of Jonathan reveals, apical heart rate of

138/min, clear breath sounds with fine crackles in the bases
bilaterally.

He has positive jugular vein distension (JVD) and bilateral 1+

pilling edema of his ankles.

You communicate your findings to his primary healthcare provider.

His initial medial diagnosis is heart failure (HF).

Mr. Peters is admitted to the acute care facility for further

evaluation and treatment.
Case Study – Question 2

Risk Factors – Heart failure occurs most commonly in clients over the
age of 60, and occurs more commonly in males than females.

In addition to these two risk factors, which question will provide the
nurse the best data about any additional risk factors for heart failure?

A. “Do you have chronic bronchitis?”

B. “Have you ever had a heart attack?”
C. “Do you have varicose veins?”
D. “Have you ever had low blood pressure?”
Case Study – Answer 2

A. “Do you have chronic bronchitis?”

• Lung disorders, such as chronic bronchitis, are not commonly associated
with an increased risk for heart failure, however, they can precipitate heart
failure.

B. “Have you ever had a heart attack?”

• MI, CAD, and ischemic heart disease are common underlying causes of HF.
The most common cause of HF is MI. The nurses should also ask Jonathan
if he has hypertension, another primary underlying condition causing HF.

C. “Do you have varicose veins?”

• Varicose veins are not associated with an increased risk for HF

D. “Have you ever had low blood pressure?”

• Systemic hypertension increases the work of the heart and is one of the
primary underlying conditions causing HF. However, hypotension is not
considered a contributory risk factor for HF.
 Case Study – Question 3

After Jonathan is seen in the clinical with a presentation that suggests a

possible diagnosis of heart failure, which laboratory results will be most
useful to monitor?

A. Serum potassium
B. β-type natriuretic peptide
C. Blood urea nitrogen
D. Hematocrit
 Case Study – Answer 3

A. Serum potassium
B. β-type natriuretic peptide
C. Blood urea nitrogen
D. Hematocrit

Research indicates that B-type natriuretic peptide levels increase in clients with
poor Lt. ventricular function and symptomatic health failure and can be used to
differentiate HF from other causes of dyspnea and fatigue such as pneumonia. A
B-type natriuretic peptide level of >400pg/ml likely indicates HF.

The other values should also be monitored but do not indicate whether the client
has HF.
Case Study – Question 4

Clinical Manifestations

Which assessment finding would indicate to the nurse that

Jonathan is experiencing right-sided heart failure?

A. Dyspnea
B. Tachycardia
C. Edema
D. Fatigue
 Case Study – Answer 4
A. Dyspnea
• Dyspnea and crackles are manifestations of Lt. sided HF results in
pulmonary congestion, due to inability of the Lt. ventricle to pump blood
out of the heart and into the system circulation effectively

B. Tachycardia
• Tachycardia is a manifestation of Lt. sided heart failure as the heart
attempts to compensate for diminishing CO

C. Edema
• Rt. Sided heart failure results in peripheral congestion due to the inability
of the right ventricle to effectively pump blood out of the heart to the
lungs, causing edema, JVD, an enlarged liver, abdominal ascites, and
weight gain

D. Fatigue
• Fatigue and anxiety are associated with Lt. sided HF. As tissues receive
 Case Study – Question 5
Cardiac Dysrhythmias: Lt-sided HF results in pulmonary fluid overload, and Rt.
Sided HF results in peripheral fluid overload. Lt. sided HF usually occurs first,
and can trigger Rt. sided HF.

Upon admission to the Cardiac Unit, Jonathan’s dyspnea continues. He

reports fatigue, but denies chest pain. The nurse placed Jonathan on O2 via
NP at 3L/min and a cardiac telemetry monitor. The ECG recording shows no
discernible P waves, and a rapid, irregular ventricular response (QRS
complexes). This corresponds with Jonathan’s pulse rate, which is 136/min
and irregular.

Which cardiac dysrhythmia is Jonathan most likely experiencing?

A. Sinus tachycardia
B. Atrial fibrillation
C. Ventricular fibrillation
D. Asystole
 Case Study – Answer 5
A. Sinus tachycardia
• Sinus tachycardia has a HR >100/min, a regular rhythm, and P waves present
B. Atrial fibrillation
• Atrial fibrillation commonly occurs in HF. Multiple areas in the atria initiate rapid,
irregular electrical stimuli, which results in the inability to see clear P waves on the
ECG. Some, but not all, of these electrical impulses travel through the AV node,
causing an irregular ventricular response. This appears as irregular QRS complexes
on the ECG recording and manifests as an irregular pulse rhythm when assessing
the client
C. Ventricular fibrillation
• Ventricular fibrillation is distinguished by totally chaotic electrical activity on the ECG
recording, with no discernible P waves or QRS complexes (ventricular response). In
addition, the client would not be arousable and would lack a pulse. This fatal
dysrhythmia require immediate defibrillation and CPR
D. Asystole
• Asystole is distinguished by a flat line (no electrical activity of any kind) on the ECG
recording. The client would not be arousable and would lack a pulse. This fatal
dysrhythmia requires immediate CPR
 Case Study – Question 6
Based on Jonathan’s cardiac dysrhythmia, which action should the nurse
implement first?

A. Administer a prescribed stat dose of digoxin

B. Notify the primary health care provider of the dysrhythmia
C. Transfer Jonathan to the Intensive Care Unit
D. Prepare for synchronized cardioversion
 Case Study – Answer 6
A. Administer a prescribed stat dose of digoxin
• If a dose of digoxin has already been prescribed, it should be administered before
taking further action. Digoxin (an inotropic agent) slows the HR and increases the
force of the heart’s contraction, which is useful in the treatment of atrial fibrillation
B. Notify the primary health care provider of the dysrhythmia
• This should be done if the nurse’s first action does not slow the ventricular rate.
Jonathan’s cardiac dysrhythmia would be considered controlled if the ventricular
response (as reflected by the QRS complexes and HR) is less than 100/min
C. Transfer Jonathan to the Intensive Care Unit
• This will probably not be necessary, but it is a possibility. Jonathan’s cardiac
dysrhythmia can result in seriously diminished CO, but it can usually be controlled. It
is not considered a life-threatening dysrhythmia
D. Prepare for synchronized cardioversion
• This procedure would be used to convert Jonathan’s cardiac dysrhythmia to a
normal sinus rhythm, but other options should be implemented first
 Case Study – Question 7

Diagnostic Studies – Jonathan is scheduled for a chest x-ray and 12 lead

electrocardiograph (ECG). Additional diagnostic studies that may be performed
include echocardiography and pulmonary artery catheterization.

Which of these diagnostic tests is used to measure the pressure within the Rt.
atrium?

A. Chest x-ray
B. Electrocardiograph
C. Echocardiography
D. Pulmonary artery catheterization
 Case Study – Answer 7
A. Chest x-ray
• Chest x-rays are useful in the diagnosis of HF, since an enlarged heart and pleural
effusions can be visualized. However, this is not the test used to measure the
pressure within the right atrium
B. Electrocardiograph
• Although an ECG is not useful in diagnosing the existence or extent of HF, it is
valuable in determining underlying myocardial ischemia or damage as well as
associated dysrhythmias
C. Echocardiography
• An echo is beneficial in the detection of cardiac valvular defects, chamber
enlargement, or pericardial effusions. This is not the test used to measure the
pressure within the right atrium
D. Pulmonary artery catheterization
• Pulmonary artery catheters are used in the management of acutely ill clients in the
critical care setting. Catheterization allows measurement of the pressures within the
right atrium and pulmonary artery, which then guides treatment
 Case Study – Question 8
Medication Administration – The primary health care provider prescribes the
following medications for Jonathan:

Captopril 12.5 mg po tid (ACE inhibitor)

Docusate sodium 100 mg po bid (Stool softener)
Metoprolol CR 25 mg po OD (Beta-blocker)
Digoxin 0.125 mg IV push q6h x 4 doses, then 0.25 mg po OD (Cardiac glycoside)
Furosemide 40 mg po, OD (Loop diuretic)
Spironolactone 12.5 mg po OD (MRA)
Dapagliflozin 10 mg po OD (SGLT2 inhibitor)

The nurse prepares a dose of digoxin (Lanoxin) 0.125 mg via IV push. The
medication is supplied as 0.25 mg in 2mL. How many mL should the nurse
prepare to give? (Enter numeric value only. If rounding is necessary, round to
the whole number.) ________
 Case Study – Answer 8

The nurse prepares a dose of digoxin (Lanoxin) 0.125 mg via IV push. The
medication is supplied as 0.25 mg in 2mL. How many mL should the nurse
prepare to give? (Enter numeric value only. If rounding is necessary, round to
the whole number.) 1
 Case Study – Question 9

Which assessment is most important for the nurse to perform prior to the
administration of captopril?

A. Apical pulse
B. Blood pressure
C. Respiratory rate
D. Intake and output
 Case Study – Question 9
A. Apical pulse
• The apical pulse should be monitored prior to the administration of digoxin (Lanoxin),
a potent cardiotonic medication used to decrease a rapid heart rate and strengthen
the force of contraction
B. Blood pressure
• Capoten is an angiotensin converting enzyme (ACE) inhibitor used as an
antihypertensive agent. ACE inhibitors have been shown to prolong survival in clients
with HF. By lowering the BP (reduced afterload), the workload on the heart is
reduced. The nurse should monitor Johnathan’s BP to ensure that the medication is
having the desired effect, and that hypotension does not occur.
C. Respiratory rate
• It is not necessary to monitor the RR prior to the administration of captopril
(Capoten)
D. Intake and output
• Intake and output are important to measure when the client is receiving furosemide
(Lasix), a potent loop diuretic
 Case Study – Question 10

The nurse explains to Jonathan that docusate sodium has been prescribed for
what purpose?

A. Prevent retention of excess body fluid

B. Maintain sufficient sodium intake
C. Prevent straining during a bowel movement
D. Strengthen the heart beat
 Case Study – Answer 10
A. Prevent retention of excess body fluid
• This is the action of furosemide, which is a potent loop diuretic

B. Maintain sufficient sodium intake

• Maintain sufficient sodium intake

C. Prevent straining during a bowel movement

• Colace is a laxative/stool softener that is administered to prevent constipation and
straining at stool. A client with cardiac problems should be instructed to avoid use of
the Valsalva maneuver (bearing down) to prevent vagal stimulation which may result
in bradycardia. The nurse should assess bowel sounds and bowel activity daily to
ensure the Colace is effective

D. Strengthen the heart beat

• This is the action of digoxin a cardiotonic medication, which is used to decrease a
rapid HR and strengthen the heart’s force of contraction
Case Study – Question 11
The nurse assesses for which expected outcome of digoxin therapy?

A. Serum digoxin level of 1.0 ng/mL

B. Serum potassium level of 4.5 mEq/L
C. Apical-radial pulse deficit
D. S1, S2, S3, and S4 heart sounds present
 Case Study – Answer 11
A. Serum digoxin level of 1.0 ng/mL
• The therapeutic level of digoxin is 0.5 to 2.0 ng/mL. Jonathan was started on a
loading dose of digoxin to reach a therapeutic level as quickly as possible. Levels
greater than 2.4 ng/mL are considered toxic. Any client receiving digitalis should be
monitored carefully for symptoms of digitalis toxicity
B. Serum potassium level of 4.5 mEq/L
• Although this is not an expected outcome of digoxin therapy, it is important that the
K level be within normal limits (3.5 to 5.0 mEq/L). Hypokalemia increases the risk
for digitalis toxicity, and hyperkalemia can also cause serious cardiac dysrhythmias
C. Apical-radial pulse deficit
• An apical-radial pulse deficit may exist if some cardiac contractions are not strong
enough to produce a pulse. This sometimes occurs in uncontrolled atrial fibrillation,
and it is not a desirable finding. The goal of digitalization is to reduce any existing
pulse deficit
D. S1, S2, S3, and S4 heart sounds present
• S1 and S2 are two normal heart sounds. S3 and S4 are considered extra heart
sounds, and they typically indicate a cardiac anomaly in the adult
Case Study – Question 12
Captopril, furosemide, and metoprolol are prescribed. The
client’s BP is 136/83mmHg, HR 70/min. Prior to medication
administration at 0900, the nurse reviews the following lab
tests (see chart). What should the nurse do first?
Laboratory Test Results (from blood sample @ 0700 same day

Sodium 140 mEq/L (140 mmol/L)

Potassium 6.8 mEq/L (6.8 mmol/L)

BUN 18 mg/dL (6.4 mmol/L)

Creatinine 1.0 mg/dL (76.3 μmol/L)

Hemoglobin 12 g/dL (120 g/L)

Hematocrit 37% (0.37)

A. Administer the medications

B. Call the primary health care provider
C. Withhold the captopril
D. Withhold the metoprolol
Case Study – Answer 12
A. Administer the medications
B. Call the primary health care provider
C. Withhold the captopril
D. Reassess the apical HR

Captopril is an ACE inhibitor, and a side effect is

hyperkalemia… Given the elevated K level, the captopril
should be held and the reported along with the K level. The
BUN & creatinine, which are normal, should be viewed prior
to administration since renal insufficiency is another potential
side effect of an ACE inhibitor. The dose of metoprolol (a
beta-blocker) should be questioned if the patient is
bradycardic. The Hgb and Hct are normal.
Case Study – Question 13
Priority Nursing Diagnoses and Interventions

Jonathan’s nurse is developing his plan of care. Which nursing

diagnosis should be include in the plan of care?

A. Fluid volume deficit

B. Ineffective airway clearance
C. Altered nutrition, greater than needs
D. Impaired gas exchange
 Case Study – Question 13
A. Fluid volume deficit
• Actually, Jonathan is experiencing fluid volume excess, since his heart is not
pumping effectively and fluid is collecting in his pulmonary and peripheral tissues

B. Ineffective airway clearance

• Jonathan is having problems with oxygenation, but these problems are not really
the result of ineffective airway clearance

C. Altered nutrition, greater than needs

• Since he has limited energy to eat, Jonathan is more likely experiencing
inadequate nutrient intake, which is not meeting his needs

D. Impaired gas exchange

• As the lung tissues become congested with fluid, less oxygen is available for
exchange, resulting in diminished tissue oxygenation. Additional high priority
diagnoses include decreased cardiac output and activity intolerance
Case Study – Question 14

Which intervention should be implemented based on the diagnosis of

activity intolerance?

A. Provide 3 large meals daily

B. Provide all activities of daily living (ADLs) for he client
C. Encourage frequent rest periods
D. Encourage regular aerobic exercise
 Case Study – Answer 14
A. Provide 3 large meals daily
• The client with activity intolerance is unlikely to have enough energy to eat 3 large
meals. Frequent small meals are a better coice to help conserve the client’s
energy

B. Provide all activities of daily living (ADLs) for he client

• The client should be encouraged to perform ADLs within the limits of his activity
tolerance to promote strength and independence

C. Encourage frequent rest periods

• The nurse should implement measures that promote rest, such as providing
adequate rest periods and assessing the need for a hypnotic medication at
bedtime. In addition, the nurse should implement measures that will reduce the
client’s energy expenditure, such as assisting with transfers and ADLs

D. Encourage regular aerobic exercise

• The client is not yet ready for aerobic exercise
 Case Study – Question 15
Nursing Interventions - The nurse enters Jonathan’s room and finds Jonathan
lying in bed in a supine position. His respiratory rate is 32/min, and he states
that his back hurts. Additional interventions implemented by the nurse
included monitoring the ECG, vital signs, degree of peripheral edema, and
daily weights. The nurse also monitors oral and IV fluid intake. The nurse
reviews the lab work to monitor serum electrolytes, specifically the potassium
level.

Which action should the nurse implement first?

A. Notify the respiratory therapist

B. Assist Jonathan to turn on his side
C. Elevate the head of Jonathan’s bed
D. Offer Jonathan a back massage
 Case Study – Answer 15
A. Notify the respiratory therapist
• This may be necessary if other measures are not sufficient to improve Jonathan’s
dyspnea
B. Assist Jonathan to turn on his side
• This is an important measure to relieve Jonathan’s discomfort, and it can be
implemented after other measures are taken to relieve Jonathan’s dyspnea
C. Elevate the head of Jonathan’s bed
• Since the nurse knows that Jonathan is already experiencing impaired gas
exchange and is obviously dyspneic, the first priority is to reduce the impaired gas
exchange. The nurse should first elevate the head of the bed and assist Jonathan
with deep breathing to promote improved oxygenation. Oxygen saturation should be
monitored via pulse oximetry, and supplemental oxygen should be provided to
maintain adequate oxygenation. Additional assessment includes breath sounds,
respiratory rate, rhythm, and effort
D. Offer Jonathan a back massage
• This can be an important measure to relieve Jonathan’s discomfort, and it can be
implemented after measures are taken to relieve his dyspnea
 Case Study – Question 16
Jonathan responds well to the plan of care. The nurse initiates client
teaching in anticipation of his discharge.

What content should the nurse include in Jonathan’s teaching plan?

(Select all that apply)

A. Monitor blood pressure prior to administration of digoxin (Lanoxin)

B. If a dose of digoxin is missed, double the next dose
C. Do not stop taking any prescribed potassium supplements
D. Regular blood draws will be necessary to measure prothrombin
time (PT) and INR
 Case Study – Question 16
A. Monitor blood pressure prior to administration of digoxin
• It is not necessary to monitor BP daily while receiving digoxin
B. If a dose of digoxin is missed, double the next dose
• A double dose may be excessive and lead to toxicity. Jonathan may be instructed to
take a missed dose within several hours, but the prescribed dose should not be
doubled
C. Do not stop taking any prescribed potassium supplements
• This is especially important if the client is taking a loop diuretic, which
causes a loss of potassium. Remember, hypokalemia contributes to
digitalis toxicity.
D. Regular blood draws to measure prothrombin time (PT) and INR
would be appropriate if Jonathan is taking Coumadin to ensure accurate
dosing and prevent complications such as bleeding or clotting
 Case Study – Question 17
Self-Management Teaching – Jonathan is discharged from the acute care
setting and resumes living at home. His daughter checks on him
frequently.

Jonathan has been taking beta-blocker carvedilol 3.125 mg po bid. What

information is most important for the nurse to have provided to Jonathan
prior to discharge? (Select all that apply)

A. Avoid abrupt transitions to an erect posture

B. Full antihypertensive effect noted in 4 weeks
C. Take with food, and restrict salt and alcohol intake
D. Do not quickly discontinue the medication
E. Do not take extra medicine to make up a missed dose
 Case Study – Answer 17
A. Avoid abrupt transitions to an erect posture
• This is the most serious adverse response to the beta-blockade. Orthostatic
hypotension can reduce blood flow to the brain, thereby causing dizziness, light-
headedness, and even syncope (fainting)

B. Full antihypertensive effect noted in 4 weeks

• It takes approximately 1 to 2 weeks for carvedilol to be effective

C. Take with food, and restrict salt and alcohol intake

• Carvedilol works best if you take it with food

D. Do not quickly discontinue the medication

• Stopping the medication suddenly may make the condition worse

E. Do not take extra medicine to make up a missed dose

• The dose should be taken as soon as the client remembers. If it is too close to
the next dose, then the medication should be skipped
Case Study – Question 18
Jonathan will be going home on Captopril 12.5 mg po bid. What
information is most important for the nurse to include in the
discharge teaching and document in the electronic medical record
(EMR)?

A. Development of cough
B. Signs of angioedema
C. Loss or altered taste
D. Fever and joint pain
 Case Study – Answer 18
A. Development of cough
• Although this is an adverse effect of ACE inhibitors it is not potentially life-
threatening and therefore not the most important

B. Signs of angioedema
• The most serious adverse effects of captopril and other ACE inhibitors are
angioedema and acute renal failure. Angioedema is manifested by facial,
perioral, epiglottal and/or extremity swelling, intestinal pain, and/or
difficulty breathing and may occur at any time during therapy

C. Loss or altered taste

• Although this is an adverse effect of ACE inhibitor, it is not potentially life-
threatening and therefore not the most important

D. Fever and joint pain

• Although this is an adverse effect of ACE inhibitors it is not potentially life-
threatening and therefore not the most important
Case Study – Question 19
Jonathan is now on Furosemide 20 mg po bid. Jonathan is aware that this
medication increases his urinary output. He asks the nurse how Lasix
helps his heart. What topic information should be included in the nurse’s
response? (Select all that apply)

A. It reduces fluid in the body

B. It improves cardiac conductivity
C. It increases venous vasodilatation
D. It reduces oxygen demand
 Case Study – Answer 19
A. It reduces fluid in the body
• Ventricular fibers contract less forcefully when they are overstretched, such as in a
failing heart. Interventions aimed at reducing preload, attempt to decrease volume
and pressure in the left ventricle, optimizing ventricular muscle stretch and
contraction. Common drugs prescribed to reduce preload are diuretics and venous
vasodilators. High-ceiling (loop) diuretics, such as furosemide (Lasix), is most
effective for treating fluid volume overload
B. It improves cardiac conductivity
• Alterations in the normal conductivity will occur with heart failure, but diuretics do
not treat dysrhythmias
C. It increases venous vasodilatation
• Increased venous vasodilatation will reduce cardiac preload but diuretics do not
cause vasodilatation
D. It reduces oxygen demand
• Reducing the workload of the heart by reducing cardiac preload, will reduce, ot
promote the heart’s consumption of oxygen
 Case Study – Question 20
Jonathan returns to the clinical several weeks later. He complains to the nurse
that he has a headache and is seeing double. He reports that he is currently
taking digoxin, furosemide, and 1 baby aspirin each day. The nurse notes that
he has had 2 diarrhea stools that day, and his pulse rate is 62/min and
irregular with frequent ectopic beats.

What is the most important intervention for the nurse to implement:

A. Assess the consistency and amount of the diarrhea

B. Obtain a serum potassium level
C. Obtain a prescription for an analgesic for Jonathan’s headache
D. Instruct Jonathan to withhold the next daily dose of aspirin
 Case Study – Answer 20
A. Assess the consistency and amount of the diarrhea
• This is an important intervention, but it is of less priority than other interventions

B. Obtain a serum potassium level

• Jonathan is exhibiting signs of digitalis toxicity and hypokalemia (low potassium). The nurse
should immediately obtain significant laboratory values, including serum potassium and digitalis
levels. Hypokalemia potentiates the effect of digitalis and can result in digitalis toxicity. Serum
potassium levels should range between 3.5 to 5.0 mEq/L. If the potassium value is 3.0 or less,
the nurse should withhold the dose of digitalis, and notify the health care provider.

C. Obtain a prescription for an analgesic for Jonathan’s headache

• Although administration of a prn prescription to help alleviate the discomfort associated with
Jonathan’s headache may be warranted, it is of less priority than other interventions

D. Instruct Jonathan to withhold the next daily dose of aspirin

• Aspirin is prescribed to reduce platelet aggregation, or clumping, which causes clot formation
that increases the risk for stroke or heart attack. It is important to monitor the bleeding time of
clients taking aspirin but there is no reason to withhold aspirin at this time
 Case Study – Question 21
What imbalance places the client taking digoxin at greatest risk of toxicity
and associated dysrhythmias?

A. Anemia
B. Leukocytosis
C. Hypercalcemia
D. Hypoalbuminemia
 Case Study – Answer 21
A. Anemia
• This will not place the client at greatest risk for digoxin toxicity

B. Leukocytosis
• This will not place the client at greatest risk for digoxin toxicity

C. Hypercalcemia
• Calcium binds with digitalis to decrease the effects of digitalis. In addition,
hypercalcemia can cause depressed cardiac activity, dysrhythmias, and cardiac arrest.
Along with serum calcium levels, the nurse should also monitor serum magnesium
levels. Hypomagnesemia is also a contributing factor to digitalis toxicity, and it can
cause dysrhythmias, hypotension, and tachycardia

D. Hypoalbuminemia
• This will not place the client at greatest risk for digoxin toxicity
 Case Study – Question 22
Jonathan is admitted to the Cardiac Observation Unit in the acute care
facility for management of his digitalis toxicity.

Digitalis toxicity can occur in up to 20% of all clients taking a digitalis

preparation. Digoxin has a narrow therapeutic index, meaning that there is
a narrow range between the therapeutic dose and the toxic dose. All
clients receiving digoxin should be monitored for digitalis toxicity. The
nurse assesses Jonathan for symptoms of digitalis toxicity.

Which manifestations are early indications of digitalis toxicity?

A. Hypertension and dizziness

B. Anorexia, nausea, and vomiting
C. Weight gain and fluid retention
D. Blurred vision and halo vision
 Case Study – Anwser 22
A. Hypertension and dizziness
• Hypotension with resultant dizziness may be a symptom of digitalis toxicity

B. Anorexia, nausea, and vomiting

• Gastrointestinal (GI) symptoms are among the earliest symptoms of digitalis toxicity,
along with confusion and fatigue. Additional manifestations include headache,
hypotension, and cardiac dysrhythmias

C. Weight gain and fluid retention

• These are not manifestations of digitalis toxicity

D. Blurred vision and halo vision

• Visual disturbances are common, but they are usually late symptoms of digitalis toxicity
 Case Study – Question 23
Jonathan’s initial admission prescriptions include:
• Continuous cardiac monitoring
• IV: 1,000mL 0.9 NS with 40 Meq KCL at 75 mL/hr
• Digoxin immune FAB (Digibind) 38 mg IV

Digibind acts by binding with digoxin already in the bloodstream, resulting in

removal of the digoxin and the prevention of further toxic effects.

Which electrolyte should be closely monitored in just a few hours after

treatment with Digibind?

A. Calcium
B. Potassium
C. Magnesium
D. Phosphate
 Case Study – Answer 23
A. Calcium
• Not significantly affected by Digibind

B. Potassium
• A precipitous drop in serum potassium may occur after treatment with Digibind

C. Magnesium
• Not significantly affected by Digibind

D. Phosphate
• Not significantly affected by Digibind
 Case Study – Question 24
A complication occurs. During Jonathan’s treatment with Digibind, the nurse
assesses that he is becoming increasingly confused and restless, and that
he has developed a frothy, productive cough. His vital signs are: T 36.7, HR
148, RR 36, BP 110/64.

Which intervention should the nurse initiate first?

A. Obtain an oxygen saturation level via pulse oximeter

B. Call the lab to obtain a stat serum potassium level
C. Collect a sputum specimen for culture and sensitivity
D. Initiate suctioning to remove lung secretions
 Case Study – Answer 24
A. Obtain an oxygen saturation level via pulse oximeter
• The first priority is to ensure adequate oxygenation. Jonathan is exhibiting symptoms of
pulmonary edema, which results in compromised oxygenation, requiring immediate action
by the nurse

B. Call the lab to obtain a stat serum potassium level

• Based on Jonathan’s symptoms, this action is not the top priority

C. Collect a sputum specimen for culture and sensitivity

• Although Jonathan may be exhibiting symptoms of a pulmonary infection, there is a higher
priority for the nurse at this time

D. Initiate suctioning to remove lung secretions

• Since Jonathan is clearing his airway by coughing, suctioning is not yet necessary
 Case Study – Question 25
Jonathan becomes increasingly restless, his dyspnea increases, as
does his tachycardia and assessment of the lungs reveal auditory
crackles. The nurses asks another nurse to contact the primary health
care provider and prepares to implement which priority interventions?
Select all that apply.

A. Administer oxygen
B. Insert foley catheter
C. Administer furosemide
D. Administer morphine sulfate IV
E. Transport the client to the coronary care unit
F. Place the client in low Fowler’s side-lying position
 Case Study – Answer 25
A. Administer oxygen (addresses gas exchange)

B. Insert foley catheter (allows for accurate output monitoring)

C. Administer furosemide (rapid-acting diuretic will act to eliminate

accumulated fluid)

D. Administer morphine sulfate IV (reduces venous return – preload;

anxiety, work of breathing)

E. Transport the client to the coronary care unit (may not be required
depending upon likely positive response to treatment)

F. Place the client in low Fowler’s side-lying position (should be high

Fowler’s
position to ease the work of breathing; with legs in dependent position if
possible)
Case Study – Question 26
Furosemide 40 mg intravenous push is prescribed.
Furosemide 10mg/mL is available. How much should the
nurse administer? Round your answer to a whole number.

_________mL
Case Study – Answer 26

What is ordered x What is available = Amount to administer

40 mg x 1 ml = 4 ml
10 mg
 Case Study – Question 27
Upon obtaining the oxygen saturation level, the nurse notes that the reading
is below 80%. The health care provider is contacted immediately. It is
requested that a stat arterial blood gas draw be performed on Jonathan.
The results are returned to the nurse and the results are:
pH 7.24
PaCO2 60 mm Hg
HCO3 27 mmol/L
PaO2 52 mm Hg

How would this reading be interpreted by the nurse?

A. Respiratory alkalosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory acidosis
 Case Study – Answer 27
A. Respiratory alkalosis (occurs when the PaCO2 is low and the pH is high)

B. Metabolic acidosis (occurs when the hCO3 is low and the pH is low)

C. Metabolic alkalosis (occurs when the HCO3 is high and the pH is high)

D. Respiratory acidosis (occurs when the PaCO2 is high and the pH is low)
 Case Study – Question 28
Ethical-Legal Issues: Decisions about Resuscitation

Jonathan is exhibiting symptoms consistent with pulmonary edema. This life-threatening

complication of HF is the result of increasing pressure in the Lt. ventricle causing fluid leakage
across the pulmonary capillary membranes. Additional manifestations of pulmonary edema
include crackles in the lung bases, frothy, blood-tinged sputum, cyanosis, cold, clammy skin,
anxiety, and sever dyspnea. The priority nursing diagnosis is “impaired gas exchange.”
Jonathan is placed on oxygen via nasal cannula at 5 L/min, and is transferred to the Medical
ICU, where IV diuresis is initiated.

Jonathan’s condition is critical, and he is disoriented and very difficult to arouse. The nurse
explains to Jonathan’s daughter, Margaret, that Jonathan’s oxygenation level is decreasing, and
he may soon require endotracheal intubation and mechanical ventilation. Margaret expresses
that she is not sure what to do because she feels that this is not the kind of treatment her father
would want.

What is the first resource Margaret and the nurse should consider during this decision-making
process?

A. The nursing code of ethics

B. The hospital’s ethics team
C. Jonathan’s advance directive
D. Jonathan’s case manager
 Case Study – Question 28
A. The nursing code of ethics (follow a code of ethics for all clinical actions, but these
general guidelines will not be useful as a resource for Margaret’s decision)

B. The hospital’s ethics team (the hospital’s ethics team is not needed at this stage of
the decision-making process)

C. Jonathan’s advance directive (a client’s advance directive provides information about

the client’s wishes for life-saving procedures and support measures. This is the best
resource to help Margaret and the nurse to determine the course of action that Jonathan
would want if he were able to make a decision at this time)

D. Jonathan’s case manager (a case manager doesn’t provide the direct information
included in the advance directive)
 Case Study – Question 29

Therapeutic Communication: Nonverbal Cues

While Jonathan is in the Medical Intensive Care Unit, the nurse

observes Margaret in the family waiting room, Margaret is sitting
alone in a dark corner of the room with her arms folded across her
chest. She is staring at the blank wall and does not answer the
telephone that is ringing next to her.

What is the best response by the nurse:

A. “I’m glad to see you are getting some rest.”
B. “Don’t you have someone to sit with you?”
C. “Acting so depressed will not help your father.”
D. “You are going through a very difficult time.”
 Case Study – Answer 29

A. “I’m glad to see you are getting some rest.” (the nurse is making an
assumption, which may or may not be accurate)

B. “Don’t you have someone to sit with you?” (this question is

challenging and belittling, which is a block to further communication)

C. “Acting so depressed will not help your father.” (giving advice is a

block to further communication)

D. “You are going through a very difficult time.” (acknowledging that an

individual is going through a difficult experience is an effective therapeutic
technique that encourages continued communication)
Case Study – Question 30
In response to the nurse’s remark, Margaret looks down at the floor,
and remains silent.

What is the best nursing action in response to Margaret’s behavior?

A. Stay seated next to Margaret and remain quietly attentive.

B. Turn on the television to provide Margaret a distraction.
C. Provide Margaret with teaching pamphlets on pulmonary edema.
D. Leave the waiting room quietly to show respect for Margaret and
give her some privacy.
 Case Study – Answer 30
A. Stay seated next to Margaret and remain quietly attentive. (silence and
offering one’s presence are effective therapeutic techniques to encourage communication)

B. Turn on the television to provide Margaret a distraction. (this action will limit
the possibility for further communication)

C. Provide Margaret with teaching pamphlets on pulmonary edema. (Margaret

has not yet demonstrated any readiness for learning)

D. Leave the waiting room quietly to show respect for Margaret and give her
some privacy. (this action will eliminate any possible further communication)
 Case Study – Question 31
Discharge Teaching: Dietary Management of a Client with HF

Jonathan’s condition steadily improves. Three days later, his condition

stabilizes, and he is transferred back to the Cardiac Unit, where the nurse
begins discharge teaching. The nurse includes dietary management in
Jonathan’s teaching plan. His prescribed diet is a 2gm sodium diet. Since he
will be taking a high dose of furosemide, he also needs instruction regarding
foods intake. Following the teaching session, the nurse evaluates what
Jonathan has learned by asking him to select an appropriate menu.

Which menu selection by Jonathan indicates that effective teaching has

taken place?
A. Canned tomato soup and a bologna sandwich on whole wheat bread
B. Roasted potatoes, fresh green beans, and grilled chicken seasoned with
lemon
C. Sliced ham, rice seasoned with salt substitute, and canned fruit cocktail
D. Cheeseburger, french fries, cookies, and a milkshake
 Case Study – Answer 31
A. Canned tomato soup and a bologna sandwich on whole wheat bread
(canned soups, whole wheat bread, and prepared luncheon meats, such as bologna, are
high in sodium)

B. Roasted potatoes, fresh green beans, and grilled chicken seasoned with
lemon (clients on restricted Na diets should be encouraged to use seasonings such as
lemon, herbs, and garlic instead of salt. Since restricting potassium is not a concern for
Jonathan, the use of a salt substitute, which is high in K, can also be included in his diet.

C. Sliced ham, rice seasoned with salt substitute, and canned fruit cocktail
(pork products, such as ham and canned products are generally high in sodium. Since
restricting K is not a concern for Jonathan, the use of a salt substitute, which is high in K, is
a good choice)

D. Cheeseburger, french fries, cookies, and a milkshake (dairy products, fried

foods, and many baked goods are high in sodium)
Case Study – Question 32
Which topics will the nurse plan to include in discharge
teaching for Jonathan?

A. How to monitor and record daily weight

B. Importance of stopping exercise if heart rate increases
C. Symptoms of worsening heart failure
D. Purpose of chronic antibiotic therapy
E. How to read food labels for sodium content
F. Date and time for follow-up appointments
 Case Study – Answer 32

A. How to monitor and record daily weight (daily weights at the same
time of day on the same scale are an important intervention for monitoring HF. Clients
should be instructed to call the health care provide with a weight gain of 2 to 3
pounds in 24 hours)

B. Importance of stopping exercise if heart rate increases (moderate

increase in HR and Respiratory effort is normal with exercise)

C. Symptoms of worsening heart failure (for seeking timely intervention)

D. Purpose of chronic antibiotic therapy (HF is not an infectious

process, thus antibiotics not a key part of Tx plan)

E. How to read food labels for sodium content (low Na diet with HF)

F. Date and time for follow-up appointments (continuity of care)

 Case Study – Question 33

If Jonathan receives a new prescription for sacubitril-valsartan

(Angiotensin receptor-neprilysin inhibitor (ARNi). Which client
information is most important to discuss with the primary health
care providers before administration of the medication?

A. The client’s oxygen saturation is 92%

B. The client receives Lisinopril 10mg/day
C. The client’s blood pressure is 150/90 mm Hg
D. The client’s potassium is 3.3 mEq/L (3.3 mmol/L)
 Case Study – Answer 33

A. The client’s oxygen saturation is 92%

B. The client receives Lisinopril 10mg/day
C. The client’s blood pressure is 150/90 mm Hg
D. The client’s potassium is 3.3 mEq/L (3.3 mmol/L)

Because combination angiotensin receptor - neprilysin blockers

(ARNI) markedly increase the risk for angioedema in clients who
are also take ACE-inhibitors (e.g. Lisinopril), the concomitant use of
both Lisinopril and sacubitril-valsartan is contraindicated. In
addition, the risk for other adverse effects such as hyperkalemia
and hypotension is increased. The other findings should be
reported to the health care provider but do not indicate a need to
withhold the sucubitril-valsartan.
 Case Study – Question 34

If Jonathan is receiving captopril and spironolactone, which

laboratory value will be most important to monitor?

A. Sodium level
B. Blood glucose level
C. Potassium level
D. Alkaline phosphatase level
 Case Study – Answer 34

A. Sodium level
B. Blood glucose level
C. Potassium level
D. Alkaline phosphatase level

Hyperkalemia is a common adverse effect of both ACE-inhibitors

and potassium-sparing diuretics. The other laboratory values may
be affected by these medications but are not as likely or as
potentially life threatening.
 Case Study – Question 35

Two weeks prior to Jonathan’s follow-up visit at the outpatient clinic

he received a new prescription for Carvedilol 12.5 mg po OD.
Which finding by the nurse who is evaluating him is of most
concern?

A. Reports of increased fatigue and activity intolerance

B. Weight increase of 0.5kg over a 1-week period
C. Sinus bradycardia at a rate of 48 beats/min
D. Traces of edema noted over both ankles
 Case Study – Answer 35
A. Reports of increased fatigue and activity intolerance
B. Weight increase of 0.5kg over a 1-week period
C. Sinus bradycardia at a rate of 48 beats/min
D. Traces of edema noted over both ankles

Research indicates that mortality is decreased when clients with HF

use beta-blocking medications such as carvedilol.

When beta-blocker therapy is started for clients with HF, HF

symptoms may initially become worse for a few weeks, so
increased fatigue, activity intolerance, weight gain, and edema are
not indicative of a need to discontinue the medication at this time.

However, a HR of 48/min indicates a need to decrease the

carvedilol dose.
 Case Study – Question 36

At the outpatient clinic, the nurse receives telephone calls from

four clients. Which client should be scheduled to be seen most
urgently?

A. Client with peripheral arterial disease who complains of leg

cramps when walking
B. Client with atrial fibrillation who reports episodes of
lightheadedness and syncope
C. Client with a new permanent pacemaker who has sever
itchiness at the wound site
D. Client with angina who took nitroglycerin twice in the last week
while exercising
 Case Study – Answer 36
A. Client with peripheral arterial disease who complains of leg
cramps when walking
B. Client with atrial fibrillation who reports episodes of
lightheadedness and syncope
C. Client with a new permanent pacemaker who has sever
itchiness at the wound site
D. Client with angina who took nitroglycerin twice in the last week
while exercising

Lightheadedness and syncope may indicate that the client’s HR is

either too fast or too slow, affecting brain perfusion and causing
risk for complications such as falls.

The other clients will also need to be seen but the data indicate
that the symptoms of their diseases are relatively well controlled.
 Case Study – Outcome
Mr. Peters is confident in his self-care. He is able to select form a variety
list of foods that are high in potassium. His selections include bananas,
raisins, cantaloupe, avocados, and raw spinach. The nurse provides
Jonathan with written dietary instructions, and Jonathan expresses
confidence that he can manage his diet effectively. Jonathan is
knowledgeable about his medications, including symptoms of digitalis
toxicity and the importance of regular lab tests for potassium and digoxin
levels. He demonstrates how to take his radial pulse correctly. He is aware
of the dates/times of his follow-up appointments. The nurse documents all
discharge teaching in Jonathan’s EMR, including Jonathan’s response to
the teaching.

What’s missing in this discharge teaching? ….Hmmmm!