Which action(s) will the nurse take when caring for a patient ...

[ts19998]

Which action(s) will the nurse take when caring for a patient with heart failure? (Select all that apply.)
 
  a. Administer diuretics at bedtime.
  b. Assess electrolyte levels.
  c. Report daily weight fluctuations.
  d. Encourage sodium intake.
  e. Maintain skin hygiene.

Question 2

Before administering digoxin (Lanoxin), the nurse takes the adult patient's apical pulse for 1 full minute. What additional nursing consideration(s) will be taken before administration of the medication? (Select all that apply.)
 
  a. Review of the digoxin blood level
  b. Administration of the medication with pulse less than 60 beats/min
  c. Review of serum electrolytes, liver, and kidney function studies
  d. Administration of the medication with a pulse of 110 beats/min
  e. Obtaining baseline patient assessment data, including lung sounds, vital signs, and weight

[ynlevi]

Answer to Question 1

ANS: B, C, E
Ongoing assessment of electrolyte levels is critical when caring for a patient with heart failure. Weight gains and losses are the single best indicator of fluid gain or loss. The maintenance of skin care and changing of positions are essential to prevent skin breakdown. Diuretics should be given in the morning and afternoon, not at bedtime, because this would interfere with sleep. Heart failure patients are prone to edema, which interferes with vascular return in the peripheral areas. Sodium restriction is one way of controlling edema.

Answer to Question 2

ANS: A, C, E
Before administering digoxin, the nurse should review digoxin levels, review baseline diagnostic data (electrolytes, liver, and kidney function tests), obtain appropriate physical assessments for heart failure patients, and verify that pulse rate is between 60 and 100 beats/min.

[ts19998]

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[ynlevi]

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