Next Generation NCLEX (NGN) Sample Questions Case Study Practice | Heart Failure NCLEX Review

hey everyone it's Sarah with registered nurse rn.com and in this video I'm going to walk you through a case study similar to what you may encounter on the Next Generation NCLEX exam so let's get started so first let's look at our case study summary we have a 68 year old male who's admitted with shortness of breath he reports a difficulty breathing with activity lying down or while sleeping he states that in order to breathe easier he has had to sleep in a recliner for the past week the patient has a history of hypertension and my cardio infarction two years ago and a cholecystectomy 10 years ago the patient is being transferred to a cardiac Progressive Care unit for further evaluation and treatment so after I read this what really jumps out at me is the patient's report about his difficulty breathing he says he has difficulty breathing with activity while lying down and while sleeping so with lying down that is called orthopnia this is when you can't really breathe very well when you lie down so you have to set up and then you can breathe easier and the difficulty breathing while sleeping is known as paroxysmal nocturnal dismia and this is like a sudden attack that happens particularly at night and the patient wakes up where they can't breathe and they have to set up to breathe so to help this the patient tells us that he's had to actually sleep in a recliner for the past week so he can breathe easier therefore whenever I see these signs and symptoms of orthopnea and paroxysmal nocturnal dysmia I'm thinking that this patient may potentially have a cardiac disorder because these are really presenting signs and symptoms whenever a patient has something wrong with her heart so their shortness of breath could be related to their heart and this is why a patient is going to the cardiac Progressive Care unit for further evaluation so now let's look at our question one of six so it says that the nurse receives the patient admitted with shortness of breath we see the nursing notes and we see the collected Vital Signs and our question wants to know what findings are significant and require follow-up and we need to select all that apply so there's going to be multiple answers so let's comb through this nursing note in vital signs to see what's abnormal and requires follow-up our nursing note starts out telling us that the patient arrived to the room via stretcher which is fine the patient is alert and oriented times four so they're alert and oriented person place and time and event and this tells us their neuros status is intact so far so the shortness of breath that they're having isn't affecting their mental function yet so right now we have enough oxygen on board for brain activity however the nurse has noticed the shortness of breath with activity and talking which should not happen normally and this tells us something is wrong it's significant requires us to follow up because we want to know why this is happening and is it going to get worse and then it goes on to tell us that the way and Vital Signs have been collected and this is good so the weight is 155 pounds the BMI is 24 which is within a healthy range now this doesn't tell us too much but it may be useful later on it also says they're connected to a bedside monitor so that's telling us that they need to be monitored constantly like on a progressive care unit and the monitor shows sinus attack and this is significant because it seems the patient's shortness of breath is causing that heart to compensate by increasing that heart rate to provide more oxygen because the lungs are probably compromised then we do find out that yes the lungs are compromised because crackles are heard in both lungs and this is probably why our patient is having shortness of breath so this is significant you want to be thinking okay do we have pulmonary edema maybe and then it says that the nurse has noted an S3 and this is like an S3 ventricular gallop and this is an extra sound that is noted after S2 and what jumps out at me about this is that this is usually associated with a volume overload like in the heart and you see this in patients who have heart failure some patients however an S3 can be normal in some people under 40 or during pregnancy but this is not the case from what we learned in our case summary at the beginning so this S3 Gallop is definitely significant and does require follow-up and in the back of my mind I'm thinking okay maybe our patient has heart failure but we need those test results back like the echocardiogram a chest x-ray and hopefully in our Labs will be a BNP so we can see what those results are it goes on to tell us that they have an 18 gauge in the left forearm which is good so we can give them medications because I bet some are going to be ordered we've had Labs drawn and our testing results are pending so now let's look at those vital signs that were collected and as we look at those you want to be asking yourself okay is this normal or not normal for this adult patient the heart rate is 112 that is high sinus Tac which confirms what we've seen on the monitor because a normal heart rate in adult should be 60 to 100. blood pressure is 176 over 98 that is hypertensive a normal blood pressure you want that top number to be less than 120 and less than 80 on the bottom the patient's oxygen saturation is on the low side and they are requiring 4 liters nasal cannula to be at 94 and generally we want it around 95 or higher so this tells me the lungs definitely are not okay and this is significant and requires follow-up and the patient's respiratory rate is increased it's 26 normal is about 12 to 20. the temperature is 98.8 that is a normal temperature and then the pain is just one out of ten So the patient's not having significant pain so since we've reviewed all this information now let's answer our question and again our question wants us to select the findings that are significant and require follow-up and there's going to be more than one answer and as we select these answers before we select it we want to make sure that it's abnormal and that it does indeed require our follow-up so be looking for answers that are abnormal with the ABCD and E so our Airway breathing circulation and so forth first up is heart rate it's 112. this is abnormal definitely this is significant we need to follow up we need to bring that heart rate down and figure out why it's so increased temperature of 98.8 that's normal that's not significant doesn't really require follow-up we'll continue to monitor for it but it's okay for now pain one out of ten that's okay does not require follow-up so we're not going to select that shortness of breath with activity and talking yes this is significant it's not normal so we are going to select that blood pressure of 176 over 98 yes this is significant we're going to select that because we need to get that blood pressure normalized weight of 155 pounds no that is not significant a BMI of 24 that is not significant either so we're not going to select either of those options sinus tachycardia yes this is significant we are going to select that respiratory rate of 26 yes that's significant we're going to select that as well S3 noted this is abnormal as I pointed out earlier so we are definitely wanting to follow up on that and then lastly an oxygen saturation of 94 on 4 liters nasal cannula this is significant and requires follow-up so we will select that now we're on question two of six and it tells us the nurse receives notification of new lab and diagnostic reports so we see that our nursing note is the same there's no added information but we do have diagnostic reports back a chest x-ray and an echocardiogram we also have Labs back that we can review and our question says for each patient finding select if is expected with left or right sided heart failure some findings may be for both types of heart failure and both columns will have at least one finding so as our case study is progressing it's starting to look like our patient does have heart failure so what we need to do is we need to go and we need to review the diagnostic reports what does our chest x-ray and Echo say and what does our Labs tell us and then we're going to go and look at what is presenting in our patient with their findings and try to select if this is last cited or right-sided heart failure so let's look at that chest x-ray the chest x-ray shows cardiomegaly which just means that the patient has an enlarged heart and mild bilateral pulmonary vascular congestion which is telling us that the patient has pulmonary edema so that is why we heard crackles before and then the echocardiogram shows that the patient has moderate left ventricular dysfunction with an lvef of 35 so lvef means it's talking about left ventricular injection fraction and an injection fraction tells us the amount of blood that is left that left ventricle with each contraction so it's telling us how well that left ventricle is pumping out blood and a normal EF is 50 or higher and less than 40 percent is associated with heart failure and our patient's EF is 35 so that's telling us our patient has a low ejection fraction and it does indeed seem like he is experiencing heart failure and to us from a nursing standpoint this is further supported with the fact that we hear an S3 gallop and we hear crackles in those lungs that tells us that blood is backing up from that left side into our lungs and causing congestion and causing the patient to have trouble breathing which will go back to that orthopna and that difficulty breathing that he was having sleeping at night which is why he had to sleep in a recliner now let's look at the patient's lab reports so here we have our patient's Labs that were ordered we see the patient's actual result and then right beside of it we see the reference range so we can see how abnormal it truly is and where it falls within the normal range so first is sodium sodium for the patient is normal but it's on the lower side of normal which can happen with heart failure because blood volume increases and it can dilute the sodium in the blood so with heart failure you definitely want to monitor for hyponatremia the patient's potassium level is normal but it is on the low end of normal so we definitely want to watch this level because chances are this patient is going to be ordered diuretics and diuretics is going to help remove that extra fluid from the body and if they're ordered Loop Diuretics like furosemide that waste potassium so we definitely want to make sure that we are watching this level and that the patient doesn't experience hypokalemia the calcium and magnesium are within normal range and the BUN and creatinine are good as well these are very important lab results that you want to watch on your patient because it tells us about their kidney function and we're going to be giving them medications that act on their kidneys so we want to make sure that their kidneys are performing well before we throw on a bunch of heart medications and diuretics we also see blood glucose which is 98 that is normal but what's not normal is the patient's BMP and it's 550 and according to the reference range here any value greater than 400 picograms per milliliter indicates there's a high probability for heart failure so it's definitely looking like our patient has heart failure so let's talk about this BNP for a second a BNP stands for brain natureuretic peptide and this is a hormone that is released by the heart muscle when there is a high pressure in the ventricles that have stretched them especially that left ventricle so this High result of the BMP really corresponds with our Echo results of what we've seen with the patient having compromised left ventricular ejection fraction and the chest x-ray where their heart is enlarged so with those diagnostic results we can see that definitely our patient has heart failure the next we see that we have troponin levels ckmb and CK levels which are all within normal range these are like cardiac markers that we'd want to look at to see if there's any damage to that heart muscle and here we're not seeing any at this moment and then the hemoglobin and hematocrit are within normal range they're a little bit on the low side of normal but that's okay right now but one thing to keep in mind with patients with heart failure is that they can experience anemia so we'd want to just keep an eye on that and then our platelets and white blood cell count are within normal range so since we've reviewed all that information now let's answer our question and again our question wanted us to select which patient findings would be be associated with left or right-sided heart failure and to help us answer this question we have to think back to the patho of heart failure and to do this try to visualize the heart in your head and divide it into the right side of the heart versus the left side of the heart and think of which side is connected to what parts of the body because what's happening in heart failure the heart is failing to pump blood forward so that blood is going to go backward and this can happen either on the right side or left side A lot of times if it's left side it's also going to affect the right side so with right sided heart failure if blood can't go forward on that right side it's going to go back into the right atrium into the vena cava which is going to hit our venous circulation so you're going to start seeing problems with liver enlargement you're also going to see jugular venous distension which is jvd in addition fluid is going to build up in the abdomen cause and ascites and the patient is going to have edema in their extremity so those are big Telltale lines of right-sided heart failure now with left-sided heart failure the blood again can't go forward so it's going to go backward it's going to go up through that left atrium and it's going to hit the lung so instead of hitting the venous circulation like our right side did on our left side it's going to hit that lung so you're going to get a lot of pulmonary symptoms where you're going to see respiratory problems the shortness of breath the crackles orthotmenia the difficulty breathing at night while you're sleeping and that pulmonary edema that you've seen on the chest x-ray so with all that knowledge in our head let's look at the patient's findings and say if it's left or right spotted so first up is shortness of breath this is a pulmonary issue this is going to happen with left-sided so we're going to select left-sided next is sinus tachycardia so is this going to be with right or left-sided heart failure with this it can actually present in both because in heart failure you have fluid volume overload and you have a weak heart so that can really tax the heart out in a last-ditch effort on its part will be to try to increase its rate so it can maintain 10 cardiac output maintain oxygen throughout the body so this can actually be for both so we're going to select both with this one chose x-ray with mild bilateral pulmonary vascular congestion that is going to be found in left-sided heart failure a blood pressure of 176 over 98 hypertension that can actually present with both right side and left side because again it goes back to that volume overload in the heart so that's going to increase pressure so we'll select both of those for this one crackles that is with the pulmonary edema that is associated with left-sided so we'll select left-sided now let's look at question three of six so we look at our nursing notes and we see that an entry has been made at 13 30 that says labs and diagnostic reports are back and Dr Smith has been notified of those results and will continue to monitor patient but there's no other new information with Diagnostics or Labs so let's look at our question it says to select the words that best complete the sentence below the sentence says the nurse suspects the patient is experiencing left-sided or right-sided heart failure so we have to select either one as evidenced by the patient's shortness of breath testing results or sinus tachycardia so this question here Builds on the question we just answered and based on what we have figured out the patient is experiencing left-sided heart failure so we really had to understand how to answer the last question in order to get this question right because it's really just bringing it all together so we already know right off the bat the patient is experiencing left-sided heart failure so we can select that now we need to figure out by what evidence does that help support that left-sided heart failure so let's look at the options we have shortness of breath well does that provide 100 evidence that yes this patient is having left-sided heart failure no not really because shortness of breath can present with other conditions like lung conditions and heart conditions so it doesn't tell us 100 the patient has heart failure how about testing results we've seen chest x-ray and echocardiogram and BNP and those were pretty convincing that the pay patients experiencing heart failure so we're going to keep that in mind but let's look at the next one which is sinus tachycardia well sinus tachycardia can present it with other conditions so that's not a hundred percent confirmation that there is heart failure going on so testing results is the best so our sentence will say the nurse suspects the patient's experiencing left-sided heart failure as evidenced by the patient's testing results so testing results is just the best to support that the patient has this now let's look at question four of six so it says the patient has been given the diagnosis of left-sided heart failure which is what we were already thinking as the nurse so that's good that it's confirmed and that we see in the nursing notes another entry has been made it tells us that Dr Smith is at the patient's bedside discussing treatment and new orders and then whenever we go down to our question our question wants us to look at those nursing actions and determine what nursing actions will be implemented for this patient and select all that apply so we see nursing actions over there on one inside and then we see implemented versus not implemented so let's go and look at what new orders we have and it looks like it's medication orders so the patient needs to be started on frostamide 40 milligrams IV twice a day and furosemide is a loop diuretic and as I pointed out earlier these can waste potassium so we definitely want to monitor our potassium levels but below that we also see that potassium 40 Milli equivalents by mouth has been ordered twice a day so hopefully that's going to help combat this hypokalemia that could potentially be experienced patients also been ordered lisinopril 2.5 milligrams po daily and lisinopril is known as an Ace inhibitor and this is going to inhibit the renin Angiotensin aldosterone system so what's this going to do is going to help with the heart failure it's going to help decrease that blood pressure help decrease the afterload the resistance which is the resistance the ventricles must overcome to pump out blood so it's going to help our heart pump more efficiently digoxin 0.25 milligrams po has been ordered daily as well and this is also going to help our heart function it's going to improve how well the heart can contract making those contractions stronger but slower and increasing our cardiac output and then morphine two milligrams IV has been ordered as needed PRN for pain or anxiety and morphine can actually help not only alleviate pain but it can have some cardiac properties as well by helping decrease our preload and our afterload and just decrease the anxiety that the patient's going to be experiencing with this pulmonary edema that they're having so help them breathe a little bit easier without the anxiety involved now let's jump back to our question and let's look at what we need to do for this patient so to answer this you need to think back to a heart failure patient what do you want to implement for them and what do you not want to implement and remember we're dealing with respiratory problems fluid volume overload new medications that can alter electrolytes and fluid status and we're dealing with a weak heart so we want to select nursing actions that's going to promote healing hints help them get better not make them worse first up is strict intake and output yes we definitely want to select this for implemented because the patient is experiencing fluid volume overload they're going to be receiving medications to promote the removal of water through their urine so we want to know exactly how much has been being taken in and how much is being put out this is going to tell us are removing enough fluid and make sure we're not hurting the kidneys that they're putting out enough urine per hour keep head of bed 15 to 30 degrees this is pretty low especially for someone who's having breathing difficulty because they have fluid in their lungs so no we would want to select not implemented for this because orthopnea is a common symptom with heart failure and lying down makes their breathing worse so we want to put them upright in like Fowler's High Fowler's position with their legs dangling to help reduce venous blood return and help decrease that prelay mode monitor for hypokalemia yes definitely we want to implement this so we'll select that because furosemide is going to waste potassium if our potassium drops too low it could actually increase the risk of digoxin toxicity which is what they're on so we want to make sure we definitely monitor the potassium levels encourage fluids no we don't want to do this so that's under not implemented because most likely this patient's going to be on a fluid restriction anywhere between 1.5 to 2 liters per day we want them to drink really only when they're thirsty and to spread this throughout the day so we don't want to just encourage them to take in lots of fluids way daily we definitely want to implement this because monitoring a patient's weight is one of the best ways we can monitor their fluid volume status and we want to do this at the same time every day with the same scale monitor EKG definitely implement this because there are risk for lethal rhythms just with heart failure in general we don't want them to go in the FIB and then plus there are on cardiac medications like digoxin we want to make sure that they're not getting bradycardic or they're having any problems with the Rhythm instruct to limit foods high in potassium no this would not be implemented because again we potentially have a problem with wasting too much potassium we don't want to limit the foods and potassium but we want them to eat a normal amount monitor apical pulse yes we want to implement this this goes back to the digoxin so you want to know as the nurse with digoxin Administration that you always measure this pulse and that you would hold it if it was less than 60 and notify the doctor for further order so we definitely want to do this monitor blood pressure absolutely this would be under implemented because again we're diuresing this patient we want to make sure that we're not going to make them hypotensive where we remove way too much fluid and we want to make sure that their blood pressure is normalizing because remember at the beginning it was high Implement a high sodium low-fat diet no this would not be implemented because just thinking back to heart failure we have fluid volume overload we know that salt sodium attracts water so they take in a lot of sodium they're going to retain a lot of water and we are not wanting this to happen because we're actually trying to remove this water so they would actually be on a low sodium diet and then lastly keep oxygen saturation greater than 95 yes we want to do this so we will click implemented now let's look at question five of six it says the nurse recesses the patient's condition after implementation of the orders so let's quickly look at our question it says what findings demonstrate the patient is improving select all that apply now let's look at what we have new so in our nursing notes we see at 1400 that medications have been given per Dr Smith's orders and the patient was educated on new medications and given a urinal to collect urine because remember they're getting diuretics so they're going to be avoiding a lot the patient verbalized understanding about the importance of helping keep track of amount you urine voided and bedside monitor connected continue to monitor then we see several hours later 1700 the patient has voided a total of 750 mL of clear yellow urine in the urinal so that tells us our diuretic is working and this is going to help decrease fluid from in the lungs lower that pressure in the heart and lower our blood pressure and then the rhythm is normal sinus rhythm on the cardiac Monitor and the patient is eating dinner with their spouse at the bedside and will continue to monitor we're told that the vital signs heart rate 88 blood pressure 130 over 80 oxygen saturation is 96 percent on three liters nasal cannula respiratory rate 16. temperature is 98.6 degrees and our pain is 1 out of ten so from that we see our heart rate has decreased our blood pressure has decreased respiratory rate is decrease and our oxygen saturation is 96 and they're actually down to three liters nasal cannula so that is good so from that new information we can see that there are some things things that tells us our patient has definitely improved so let's see what our options are the temperature of 98.6 that is still normal so it's the same so we're not going to select that really there's been no improvement it's maintained itself 750 mL of voided urine that is a good sign and that shows us the patient is improving they're getting rid of this fluid that's in their heart and their lungs so they can function easier so we're going to select that next is patient is eating does this show us that the patient is improving and the answer is yes it actually does because let's think back to eating eating takes a lot of breathing effort you have to chew and you have to swallow and whenever you have a patient who has respiratory issues like this patient here with shortness of breath it can really tax them with just the task of eating so the fact that they're up and eating tells us that the respiratory system must be doing okay if they feel like eating plus they have an appetite and they're not nauseous or experiencing vomiting which is something you definitely want to watch for whenever a patient's taken digoxin because GI upset is one of the early signs and symptoms of digoxin toxicity so this tells me that it's a good sign so we're going to select this three liters nasal cannula this is an improvement from before because remember at the beginning of our case study our patient was on four liters so they're maintaining 96 on three liters so this is an improvement pain of 1 out of ten this is the same we're not going to select this and then normal sinus rhythm this is definitely an improvement because before the patient was experiencing sinus tachycardia and then finally question six of six so here we're told after a few days of hospitalization the patient is ready to go home the nurse is providing discharge education to the patient and the question in this part of the case study says the nurse has provided discharge care instructions about heart failure to the patient what statements by the patient require re-education so let's look and see what new information we have we we see in our nursing notes at nine o'clock that discharge orders have been received home health nurse is present with a patient discussing program options and Home Care set up a lot of times patients who have heart failure will go home with a home health nurse who will come out to see them and just help monitor their heart failure and then we see the discharge medications that the patient's going to go home on which is like frostamide potassium lisinopril and digoxin so to answer this question what we need to do is we need to look at the patient statement and then ask yourself is this something a patient with heart failure should do and if it's not they need to be re-educated the first one is I will notify my doctor if I gain more than two pounds in a day this is a correct statement so no re-education is needed with heart failure the patient wants to make sure that they don't gain more than two to three pounds in a day or five pounds in a week if they do they need to contact their doctor because it can be an early sign that heart failure is coming on and that that heart is starting to fail and it can't deal with the extra fluid next I will weigh myself at the same time each week this is not a correct statement so re-education is needed the patient should weigh themselves daily at the same time each day not weekly and weight gain is an early sign that the patient is gaining fluid and the heart is starting to fail so if they do have this happen they would want to contact their doctor for further care next nausea and vomiting is an expected side effect of my medications this is incorrect and requires re-education the patient is actually going home on digoxin and as I discussed before digoxin has a risk of toxicity with it and this risk actually increases with hypokalemia which the patient could potentially experience since they're on furosemide and nausea and vomiting is one of those early signs and symptoms therefore the patient really needs to be educated if they experience this they should report it immediately and not just dismiss it as an expected side effect I will miss eating spinach broccoli bananas and avocados this is an incorrect statement re-education is needed so with this how you would know is you need to ask yourself okay what do all these foods that the patient just listed what do they have in common well they have in common is that they're all high in potassium and the patient shouldn't limit these Foods because again we have a risk of hypokalemia with a frostamide they want to eat a normal male of potassium along with taking their potassium supplement not to just cut off potassium completely I will follow a low sodium diet this is correct so no re-education is needed because patients with heart failure should consume less than two grams which is 2 000 milligrams of sodium per day and also they want to watch out for hidden sodium and like soft drinks and processed foods because remember water loves sodium and more sodium draws in more water which can exacerbate heart failure and then lastly I will use sugar-free candies if I develop a dry hacking cough this is an incorrect statement and re-education is needed so we'll select that now a dry hacking cough should not be ignored because it could could be a sign that heart failure is getting worse and that the patient needs to be evaluated it's one of those early signs along with the weight gain however one thing you want to remember is that lisinopril which is an Ace inhibitor can cause a dry hacking cough however regardless of this this dry hacking cough should be evaluated and not just ignored by sucking on hard candies to keep it from happening because the cough could be due to like maybe the lisinopril which the doctor could switch them to an Angiotensin receptor blocker an arm or indeed the heart failure is exacerbating itself so they need to be further evaluated okay so that wraps up this video if you'd like to watch more videos in this series you can access the link in the YouTube description below

Channel: RegisteredNurseRN

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Keywords: next generation nclex, next generation nclex case study, case study ngn, ngn case study, ngn practice questions, next generation nclex practice questions, next generation nclex live review, nclex review, nclex rn review, ngn heart failure, next generation nclex heart failure review, heart failure, heart failure case study, next generation nclex practice problems, next generation nclex sample questions, ngn sample questions, ngn, ngn case study questions, nclex practice question

Id: RQpYx1aSTsQ

Length: 29min 41sec (1781 seconds)

Published: Tue Apr 04 2023