NCLEX-PN NextGen Cardiovascular Nursing, ECG Rhythms & Heart Failure (Unfolding Clinical Judgment Blueprint)

Left vs Right Sided Heart Failure Symptoms: LEFT-SIDED HEART FAILURE (Lungs): • Pulmonary Congestion & Crackles / Wheezes • Dyspnea, Orthopnea, Paroxysmal Nocturnal Dyspnea (PND) • Cough with Pink Frothy Sputum (Pulmonary Edema) • Decreased Cardiac Output (Fatigue, Oliguria, Confusion) RIGHT-SIDED HEART FAILURE (Rest of Body / Systemic): • Jugular Vein Distention (JVD) • Peripheral Dependent Pitting Edema (sacrum, ankles) • Hepatomegaly & Splenomegaly (Ascites) • Weight gain (> 2 lbs in 24 hrs or 5 lbs in a week) ---------------------------------------- PRACTICE BOARD QUESTION & RATIONALE: Q: A client with chronic heart failure taking Digoxin 0.25 mg daily reports nausea, anorexia, and seeing yellow-green halos around room lights. What is the nurse's immediate priority? A. Document as expected findings of digitalization B. Check the apical pulse, withhold the drug, and obtain a serum digoxin level C. Administer an oral antiemetic 30 minutes before the next dose D. Encourage consumption of potassium-rich foods immediately Correct Answer: B. Anorexia, nausea, and yellow halos (xanthopsia) are classic toxic signs of Digoxin toxicity (therapeutic range: 0.5 - 2.0 ng/mL). Check apical pulse (hold if <60 bpm) and notify the physician.