A client visits the healthcare clinic complaining of increasing
fatigue and difficulty breathing. Physical assessment findings include a rapid, irregular heart rate
of 138 beats/min, BP of 140/86 mm Hg, and a respiratory rate of 28 breaths/min. His breath
sounds are clear with fine crackles in the bases bilaterally. He has positive jugular vein
distention (JDV) bilaterally and 1+ pitting edema of his ankles bilaterally. His initial medical
diagnosis is heart failure (HF). Jonathan is immediately admitted to the acute care facility for
further evaluation and treatment.
Risk factors
Heart failure occurs most commonly in clients over the age of 60 and occurs more commonly in
males than females.
Question 1: In addition to these two risk factors, what other risk factors will provide the nurse
with the best data for the heart?
Clinical Manifestations
Question 2: Name one assessment finding indicating that Jonathan is experiencing right-sided
heart failure.
Cardiac Dysrhythmias
Left-sided heart failure results in pulmonary fluid overload, and right-sided heart failure results in
peripheral fluid overload. Left-sided heart failure usually occurs first and can trigger right-sided
heart failure.
Upon admission to the Cardiac Nursing Unit, Jonathan’s dyspnea continues. He reports fatigue
but denies chest pain. The nurse places Jonathan on oxygen via a nasal cannula 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 and irregular.
Question 3: What cardiac dysrhythmia is Jonathan most likely experiencing?
Question 4: Based on Jonathan’s cardiac dysrhythmia, what would the nurse implement first?
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.
Question 5: Name the diagnostic test used to measure the pressure within the right atrium?
Medication Administration
The HCP prescribes the following medications for Jonathan:
Digoxin (Lanoxin) 0. 125 mg IV every 6 hours x 4 doses, then 0.25 mg orally, daily
Furosemide (Lasix) 40 mg IV push, daily.
Captopril (Capoten) 12.5 mg orally, three times a day
Docusate sodium (Colace) 100 mg orally, twice a day.
Carvedilol (Coreg) 3.125 mg orally, twice a day.
Warfarin (Coumadin) 5 mg orally, daily.
Question 6: The nurse prepares a dose of digoxin )Lanoxin) 0.125 mg via IV push. The
medication is supplied as 0.25 mg in 2 mL. How many mL should the nurse prepare to give?
(Enter numeric value only. If rounding is necessary, round to the whole number).
Question 7: What assessment is the most important prior to the administration of captopril
(Capoten)?
Question 8: What is the expected outcome of digoxin (Lanoxin) therapy?
Nursing Diagnoses and Interventions
Question 9: List one priority nursing diagnosis to be included in the plan of care.
Question 10: List one intervention that should be implemented based on the diagnosis of activity
intolerance