Your client: Chester Payne Age: 78 years old Past medical history. History of persistent atrial fibrillation, hypertension, hyperlipidemia and osteoarthrosis. Yesterday: Client was admitted for a diagnosis of atrial fibrillation with rapid ventricular response (RVR). Later in the day, the client's heart rhythm was converted to normal sinus rhythm using intravenous medication therapy. 0900 today: Client is sitting up in the bedside recliner. Client reports "racing heartbeat" and feeling "like I can't get a good deep breath" Upon auscultation the nurse hears an irregular heart rhythm. Assessment is as follows: Neurological: Alert and oriented x 4 Eyes, Ear, Nose, and Throat (EENT): Normocephalic, denies sore throat, denies nasal congestion, denies vision changes. No swelling or drainage visualized. Pulmonary: Reports some shortness of breath (SOB), no cough. Lungs sound clear in all fields. Cardiovascular: Irregular heart rhythm auscultated. Denies chest pain. Skin is warm and dry to the touch. Capillary refill > 3 seconds. 2+ bilateral lower extremity edema. Peripheral pulse 1+ equal bilaterally. Jugular vein distention (JVD) is noted Gastrointestinal: Abdomen rounded and firm. Reports slight nausea, bowel sounds hypoactive x 4 quadrants. Reports bowel movement prior to admission. Genitourinary: Voiding clear yellow urine without issues as per client self-report. Musculoskeletal: Full range of motion against resistance. The nurse expects the doctor to order what medication(s) for this patient?
Explanation & Rationale
A. IV fluid bolus of normal saline at 250 ml/hour: Administering a fluid bolus would be detrimental to a client already showing signs of volume overload, such as JVD and peripheral edema. This intervention would exacerbate the heart failure and worsen the client's respiratory distress. Fluid restriction is more likely indicated in this clinical scenario. B. Furosemide and a calcium channel blocker: Furosemide will address the systemic edema and JVD by promoting diuresis and reducing fluid volume. A calcium channel blocker, such as diltiazem, is standard for rate control in atrial fibrillation to slow the ventricular response. This combination treats both the symptomatic fluid overload and the underlying arrhythmia. C. Pantoprazole and digoxin: While digoxin can be used for rate control, pantoprazole is a proton pump inhibitor for gastric acid and does not address the client's primary cardiac issues. Digoxin alone would not treat the significant peripheral edema or JVD noted in the assessment. The primary goal is diuresis and rapid rate stabilization. D. IV potassium and antibiotics: Antibiotics are used for bacterial infections, which are not suggested by the clear lung sounds and lack of fever. Potassium is only replaced if a deficit is confirmed via laboratory testing. These medications do not address the acute needs of a client in heart failure with a rapid heart rate.