Question

(abnormal cardiac rhythm) diastolic heart failure pt. which is the most appropriate action for nurse to take?

- digoxin 0.25mg IV
- instruct pt to take deep breath and hold it
- assess LOC and orientation
- auscultate posterior chest

Answer 1

In a patient with heart failure and arrhythmia, the initial action should be to assess LOC and orientation, as this gives vital information about the patient's neurological status and potential deterioration.

Step-by-step explanation:

In the case of a patient with diastolic heart failure and an abnormal cardiac rhythm, the most prudent initial action for a nurse would be to assess the patient's level of consciousness (LOC) and orientation. This assessment provides immediate information on the patient's neurological status and potential deterioration, which is essential in the acute management of arrhythmias. It is critical before administering medications like digoxin or before considering interventions such as using a defibrillator to correct an arrhythmia.

Auscultation of the posterior chest, while important for assessing overall respiratory function, is secondary in urgency to evaluating neurological function in this scenario. Instructing the patient to take a deep breath and hold it could be part of a broader assessment but is not the most immediately relevant action.