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","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.

A. Explain the association between dysrhythmias and syncope. B. Tell the patient about the benefits of implantable cardioverter-defibrillators. C. Instruct the patient to call for assistance before getting out of bed. D. Teach the patient about the need to avoid caffeine and other stimulants.

Correct Answer is C

Explanation

For a patient admitted with syncopal (fainting) episodes of unknown origin, the most appropriate action to include in the plan of care is to instruct the patient to call for assistance before getting out of bed.

Syncope can be caused by various factors, including orthostatic hypotension (a drop in blood pressure upon standing) or cardiac-related issues. One of the common triggers for syncopal episodes is getting up from a lying or sitting position too quickly. By instructing the patient to call for assistance before getting out of bed, the nurse aims to prevent falls and potential injuries that may occur due to sudden fainting episodes.

While it's essential to educate the patient about potential causes of syncope (option A) and the benefits of implantable cardioverter-defibrillators (option B) if applicable to their condition, these actions may not directly address the immediate safety concern of preventing falls during syncopal episodes.

Option D, teaching the patient about the need to avoid caffeine and other stimulants, may be relevant if stimulants are identified as potential triggers for syncope in this particular patient. However, it is not the most critical action to include in the initial plan of care for a patient with syncopal episodes of unknown origin.

In summary, the top priority for the nurse is to ensure the safety of the patient by instructing them to call for assistance before getting out of bed to prevent falls during syncopal episodes until further evaluation and diagnosis can determine the cause of the fainting episodes.

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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 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

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

Correct Answer is C

Explanation

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