Comprehensive case-based practice covering CAD, Cardiomyopathy, Heart Failure with integrated BPH and UTI complications. Self-scoring format with detailed rationales.
ProgressScore: 0 / 0
Client Case Chart
Initial Presentation (0900): 65-year-old client presents to ED with shortness of breath and severe pain from bladder distention.
Background History
PMH: CAD (2005), HTN (2012), CKD stage I (2015), MI (2019), Dilated cardiomyopathy (2020), BPH (2023)
Presenting: BP 140/90 mm Hg, HR 125 bpm
Pain Level: 8/10 (bladder distention)
Physical Assessment
Vitals: T 101°F (oral), HR 125 bpm, BP 140/90 mm Hg, RR 25/min, SpO₂ 85% on room air
HEENT: Alert and oriented ×1 only
Cardiac: Systolic murmur noted
Pulmonary: Labored breathing, coarse crackles at bilateral lung bases
Case adapted from NGN-driven cardiovascular scenario with integrated urologic complications. Content aligned with NCSBN Clinical Judgment Measurement Model.
1. Recognize Cues
Identify relevant assessment data from the available information.
1.1 Rhythm Recognition: What abnormalities are present on the 5-lead ECG tracing?
Select all that apply (SATA)
Rationale
P wave abnormalities: Atrial fibrillation characteristically lacks organized P waves; instead, you observe chaotic fibrillatory activity throughout the baseline.
QRS complex width: In uncomplicated AF, the QRS duration remains normal unless there is concurrent bundle branch block or ventricular conduction defect. Width alone is not diagnostic of AF.
1.2 Classification: This dysrhythmia originates from which cardiac structure?
Rationale
The dysrhythmia arises from disorganized electrical activity in the atria rather than the ventricles. Multiple atrial foci fire chaotically, overwhelming the SA node's normal pacemaker function.
1.3 Identification: Name the specific rhythm disorder.
Rationale
Atrial fibrillation presents with an irregularly irregular rhythm without distinct P waves. The elevated ventricular rate indicates rapid ventricular response (RVR), requiring immediate rate control intervention.
1.4 Priority Assessment: Which findings require immediate follow-up?
Select all that apply — choose all critical findings
Rationale
Respiratory compromise: SpO₂ 85%, tachypnea, labored breathing, and crackles indicate left-sided heart failure with pulmonary congestion requiring immediate oxygen therapy and diuresis.
Cardiac issues: HR 125 bpm with AF requires rate control assessment; acute confusion suggests inadequate cerebral perfusion from low cardiac output.
Genitourinary crisis: Two-day anuria with BPH history indicates urinary retention with infection risk and potential post-renal AKI. Immediate catheterization needed.
Allergy consideration: Banana allergy raises latex sensitivity concerns before any invasive procedures or catheter placement.
Fever significance: Temperature elevation suggests possible UTI or sepsis from prolonged urinary retention.
Pain management: Severe bladder distention pain (8/10) requires urgent intervention.
Lower priority: While BP 140/90 and systolic murmur warrant attention, they are not immediately life-threatening compared to hypoxemia and urinary retention.
2. Analyze Cues
Connect assessment findings to potential underlying conditions and pathophysiology.
2.1 Pattern Recognition: Associate assessment findings with cardiomyopathy classification
Select all appropriate associations in the matrix
Assessment Finding
Dilated CMT
Restrictive CMT
Hypertrophic CMT
Elevated blood pressure
Elevated heart rate
Hepatomegaly
Splenomegaly
Pulmonary congestion
Elevated respiratory rate
Rationale
Each listed clinical finding can manifest across all three major cardiomyopathy types—dilated, restrictive, and hypertrophic—though the underlying mechanisms differ:
Dilated cardiomyopathy: Chamber enlargement with poor contractility leads to backward failure and congestion
Hypertrophic cardiomyopathy: Abnormal wall thickening reduces chamber volume and can obstruct outflow
All three types ultimately result in compromised cardiac output, systemic compensation (tachycardia, hypertension), and congestive symptoms when decompensated.
3. Prioritize Hypotheses
Determine which nursing diagnoses are most relevant to the current clinical situation.
3.1 Nursing Diagnosis Selection: Which diagnoses are appropriate for this client now?
Select all that apply
Rationale
Electrolyte imbalance: Anticipated with heart failure diuretic therapy and dysrhythmia management requiring close monitoring of K⁺, Na⁺, and Mg²⁺
Impaired breathing pattern: Evidenced by SpO₂ 85%, RR 25/min, labored respirations, and bilateral crackles from pulmonary congestion
Decreased cardiac output: Supported by tachycardia, hypoxemia, acute confusion, dilated cardiomyopathy with EF 30%, and AF with RVR
Infection: Fever (101°F), leukocytosis (WBC 13,000), and two-day anuria strongly suggest urinary tract infection with potential sepsis risk
Not priority: While coping may be relevant during recovery, the current physiologic instability takes precedence over psychosocial diagnoses
4. Generate Solutions
Evaluate proposed interventions based on the clinical situation and evidence-based practice.
4.1 Intervention Evaluation (Pre-Laboratory Results): Classify each intervention
Indicate whether each action is Indicated (I), Contraindicated (C), or Non-essential (NE)
Proposed Intervention
Classification
Contact urology to insert 18F indwelling Foley catheter STAT
Start 0.9% NaCl IV at 100 mL/hr continuous infusion
Verify iodine/shellfish allergy status before cardiac catheterization
Obtain BUN and creatinine levels
Administer Digoxin 125 mcg PO daily
Administer Lisinopril 25 mg PO daily
Rationale
Foley catheter (Indicated): Urgent relief of urinary retention in BPH patient; urology consultation appropriate for difficult catheterization. Latex-free catheter essential due to banana allergy.
IV fluids (Contraindicated): Continuous normal saline infusion would exacerbate acute decompensated heart failure with existing pulmonary congestion and hypoxemia. Patient needs diuresis, not volume expansion.
Allergy verification (Indicated): Essential before any contrast-enhanced imaging (angiography, cardiac catheterization) to prevent anaphylaxis. Document iodine and shellfish allergies.
Renal function tests (Indicated): Baseline BUN/Cr necessary before contrast procedures and to assess kidney function with oliguria. Also guides diuretic and ACE inhibitor dosing.
Digoxin (Non-essential): Rate control may be beneficial for AF, but administration must wait until potassium level is confirmed. Hypokalemia dramatically increases digoxin toxicity risk. Hold until K⁺ known and within therapeutic range.
Lisinopril (Indicated): ACE inhibitor provides afterload reduction beneficial in heart failure and helps manage hypertension. Blood pressure (140/90) tolerates this therapy.
4.2 Additional Intervention Evaluation: Classify these proposed orders
Determine appropriateness based on current clinical presentation
Proposed Intervention
Classification
Administer Furosemide 20 mg IV push ×1 dose
Initiate oxygen therapy 2–6 L/min via nasal cannula to maintain SpO₂ ≥95%
Administer regular insulin sliding scale three times daily
Start Vancomycin 1.5 g IV in 500 mL over 4 hours ×1 (with peak/trough monitoring)
Rationale
Furosemide (Indicated): Loop diuretic essential for treating pulmonary congestion evidenced by crackles, hypoxemia, and heart failure. Reduces preload and improves oxygenation. Monitor electrolytes closely.
Oxygen therapy (Indicated): Critical intervention for SpO₂ 85%. Titrate oxygen to maintain saturation ≥95% while monitoring for improvement in work of breathing and mental status.
Insulin sliding scale (Non-essential): No documented history of diabetes mellitus in the chart. Unless blood glucose testing reveals hyperglycemia, this intervention is not indicated at present.
Vancomycin (Indicated): Broad-spectrum antibiotic appropriate for suspected urinary tract infection with fever and leukocytosis. Covers resistant organisms pending culture and sensitivity results. Monitor renal function and vancomycin levels due to nephrotoxicity risk, especially with CKD history.
Laboratory and Diagnostic Results (1200 Hours)
Complete Blood Count
WBC: 13,000/mm³ ↑
Hemoglobin: 9 g/dL ↓
Hematocrit: 20% ↓
Platelets: 400,000/mm³ (normal)
Basic Metabolic Panel & Cardiac
Sodium: 125 mEq/L ↓
Potassium: 3.0 mEq/L ↓
Magnesium: 2 mEq/L (normal)
Phosphorus: 3 mg/dL (normal)
Calcium: 9 mg/dL (normal)
BNP: 1000 pg/mL ↑
BUN: 20 mg/dL (normal)
Creatinine: 1.4 mg/dL (elevated)
Diagnostic Findings
Urine C&S:E. coli growth; resistant to piperacillin/tazobactam and amoxicillin
Chest X-ray: Pulmonary infiltrates with consolidation in right and left lower lobes
12-lead ECG: U waves visible in leads II, III, aVF; inverted T waves in V1–V4
Low EF (30%): Severely reduced systolic function consistent with dilated cardiomyopathy
Anemia (Hgb 9, Hct 20%): Chronic disease vs. GI blood loss; reduces oxygen-carrying capacity
UTI with resistance:E. coli requires antibiotic adjustment based on sensitivities
5. Take Action
Implement appropriate nursing interventions based on laboratory results and evolving clinical picture.
5.1 Priority Nursing Actions: What should the nurse implement now?
Select all appropriate interventions based on the laboratory results
Rationale
Hold digoxin: Potassium level of 3.0 mEq/L significantly increases risk of digoxin toxicity. Must correct hypokalemia before administering cardiac glycosides. Check serum digoxin level; therapeutic range is 0.5–2 ng/mL.
Potassium replacement: Critical intervention for K⁺ 3.0 mEq/L. May require IV supplementation depending on facility protocol. Monitor ECG changes (U wave resolution) and recheck levels.
Oxygen therapy: Continue titrating supplemental oxygen to maintain SpO₂ ≥95%. May need to increase flow rate or transition to high-flow device if hypoxemia persists despite current therapy.
Diuresis: IV furosemide addresses pulmonary congestion. Monitor urine output, daily weights, lung sounds, and electrolytes. Goal is negative fluid balance with symptom improvement.
Avoid fluid bolus: Normal saline bolus is contraindicated in acute decompensated heart failure with pulmonary edema. Would worsen fluid overload and respiratory distress. Hyponatremia is dilutional from excess total body water, not volume depletion.
Provider notification: Critical lab values require immediate communication: hyponatremia (125 mEq/L) and hypokalemia (3.0 mEq/L) need management plans. Use SBAR format.
Antibiotic therapy: Adjust coverage based on culture showing E. coli resistant to pip/tazo and amoxicillin. Vancomycin may need modification. Monitor vancomycin trough levels and renal function.
Positioning: Semi-Fowler's or high Fowler's position (30–45° or higher) uses gravity to reduce venous return and improve lung expansion, decreasing work of breathing.
Allergy confirmation: Document iodine/shellfish allergies clearly before cardiac catheterization. Ensure radiology and cardiology teams are aware. Pre-medication protocols may be needed.
Urinary catheter: Essential for monitoring output during diuresis and relieving retention. Urology placement appropriate for BPH complexity. Use latex-free catheter due to banana allergy (potential latex cross-reactivity).
6. Evaluate Outcomes
Assess whether interventions achieved desired results or if the client's condition has changed.
6.1 Outcome Assessment (Day 4): Classify each finding as Improved, No Change, or Declined
Compare Day 4 findings to admission baseline
Assessment Finding (Day 4)
Status
Blood pressure 120/90 mm Hg (was 140/90)
Heart rate 100 bpm (was 125)
Potassium 5.0 mEq/L (was 3.0)
Sodium 145 mEq/L (was 125)
Respiratory rate 16/min (was 25)
Hemoglobin 9 g/dL (unchanged)
SpO₂ 95% on 6 L nasal cannula (was 85% on RA, then 2 L)
ECG: Persistent U waves in inferior leads
Rationale
Improved parameters:
Blood pressure: Reduced from 140/90 to 120/90 indicates improved afterload and reduced cardiac workload
Heart rate: Decreased from 125 to 100 bpm suggests better AF rate control and reduced sympathetic stimulation
Electrolytes: Potassium normalized (3.0 → 5.0 mEq/L) and sodium corrected (125 → 145 mEq/L) show effective replacement and diuresis
Respiratory rate: Reduction from 25 to 16/min with presumably less labored breathing indicates improved oxygenation and reduced pulmonary congestion
No change:
Hemoglobin: Remains 9 g/dL; chronic anemia unchanged. May need further investigation and possible transfusion consideration depending on symptoms.
Declined/concerning:
Oxygen requirement: Despite achieving target SpO₂ of 95%, the client now requires 6 L/min oxygen compared to 2 L initially. This increased requirement suggests worsening gas exchange, possible progression of pulmonary edema, or development of pneumonia (CXR showed infiltrates).
Persistent U waves: Despite potassium correction to 5.0 mEq/L, U waves remain on ECG. This may indicate incomplete intracellular potassium repletion, concurrent hypomagnesemia, or other electrolyte abnormalities. Requires continued monitoring and possible further supplementation.
Clinical concern: The increasing oxygen requirement despite other improvements warrants reassessment for pneumonia progression, pulmonary embolism, or inadequate diuresis. Consider repeat CXR, ABG analysis, and pulmonary consultation.
Cardiac Catheterization Preparation (Day 3)
Pre-procedure assessment and intervention planning for planned cardiac catheterization via femoral approach.
Classify each intervention as Indicated, Contraindicated, or Non-essential
Intervention
Classification
Monitor femoral access site for bleeding, hematoma, or ecchymosis post-procedure
Maintain flat bed rest for 6–8 hours; assist with bedpan use
Confirm documented iodine and shellfish allergies; notify radiology
Hold Metformin for 48 hours before and after procedure (if applicable)
Verify current BUN and creatinine levels before contrast administration
Hold Metoprolol PO the morning of the procedure
Rationale
Femoral site monitoring (Indicated): Essential post-procedure surveillance for bleeding complications, hematoma formation, or pseudoaneurysm. Check distal pulses, assess for expanding masses, and monitor vital signs.
Activity restriction (Indicated): Flat bed rest with affected leg straight for 6–8 hours (or per protocol) prevents arterial disruption and bleeding. Use bedpan to avoid hip flexion. Monitor for back discomfort.
Allergy confirmation (Indicated): Critical safety step. Document banana allergy (latex sensitivity) and any iodine/shellfish allergies. Radiology team must use latex-free equipment and may pre-medicate with antihistamines and steroids for contrast allergy.
Metformin hold (Indicated): If patient were taking Metformin (not specified in this case), must hold 48 hours before and after contrast administration to prevent lactic acidosis, especially with renal impairment. Resume only when renal function stable.
Renal function verification (Indicated): Current BUN/Cr essential to assess contrast-induced nephropathy risk. Patient has CKD stage I and elevated Cr (1.4), requiring pre- and post-procedure hydration protocols and possibly N-acetylcysteine prophylaxis.
Beta-blocker hold (Contraindicated): Do NOT routinely hold beta-blockers before cardiac catheterization unless specifically ordered by the cardiologist. Beta-blockers provide important rate control (especially with AF), anti-ischemic effects, and blood pressure management. Sudden withdrawal can cause rebound tachycardia and hypertension. Continue Metoprolol unless provider directs otherwise.
Key principle: Maintain cardiac medications through procedures unless contraindicated or specifically held by the proceduralist. Beta-blockers, ACE inhibitors, and antiplatelet agents typically continue; anticoagulants may be adjusted based on bleeding risk.
Bonus: Advanced Practice Questions
Challenge questions integrating complex clinical reasoning across multiple body systems.
H1. Furosemide Monitoring: Which laboratory values require reassessment with loop diuretic therapy?
Select all that apply
Rationale
Potassium and magnesium: Loop diuretics cause significant urinary losses of K⁺ and Mg²⁺, potentially leading to dangerous hypokalemia and hypomagnesemia. Monitor closely and supplement as needed.
Renal function: Aggressive diuresis can reduce renal perfusion, elevating BUN and creatinine. Pre-renal azotemia risk increases with over-diuresis. Balance fluid removal with kidney protection.
BNP trending: Serial BNP measurements help assess heart failure treatment response. Levels should decrease with effective diuresis and symptom improvement.
Liver enzymes: Not directly affected by furosemide; hepatic function tests are less relevant for routine loop diuretic monitoring unless hepatic congestion from right heart failure is present.
H2. AF with RVR Management: Most appropriate initial rate control for stable patient (SBP 128 mm Hg)?
Rationale
Diltiazem IV is the preferred initial rate control agent for AF with RVR in hemodynamically stable patients. Alternatives include IV metoprolol or other beta-blockers.
Epinephrine: Absolutely contraindicated—would worsen tachycardia and increase myocardial oxygen demand
Adenosine: Used for SVT termination (PSVT), not effective for AF rate control
PO Amiodarone: Slow onset (days to weeks); not appropriate for acute rate control, though may be used for rhythm control long-term
Diltiazem: Rapid onset, effective AV nodal blockade, well-tolerated in stable patients. Monitor blood pressure during infusion.
H3. Fluid Overload Assessment: Which findings most strongly indicate volume excess in heart failure?
Select all that apply
Rationale
Peripheral edema + crackles: Classic combination of right-sided (dependent edema) and left-sided (pulmonary congestion) heart failure manifestations
Rapid weight gain: 2 kg in 48 hours represents approximately 2 liters of fluid retention—highly specific for fluid overload. Daily weights are the most sensitive monitor.
Orthopnea: Inability to lie flat due to increased venous return and pulmonary congestion is pathognomonic for heart failure. Paroxysmal nocturnal dyspnea (PND) similarly indicates volume overload.
Low-grade fever: Nonspecific finding; may indicate infection but does not directly suggest fluid overload
H4. ACE Inhibitor Education: Which teaching points are essential for Lisinopril therapy?
Select all appropriate education points
Rationale
Potassium restriction: ACE inhibitors increase serum potassium by reducing aldosterone. Avoid K⁺-containing salt substitutes (Morton Salt Substitute, No Salt) and limit high-potassium foods unless directed. Monitor labs regularly.
Angioedema warning: Rare but life-threatening complication. Any swelling of face, lips, tongue, or throat requires immediate emergency care and ACE inhibitor discontinuation. More common in African American patients.
Orthostatic precautions: ACE inhibitors lower blood pressure; first-dose hypotension possible. Teach slow position changes, sitting at bedside before standing, and recognition of presyncope symptoms.
ACE cough: Chronic dry cough occurs in up to 10–15% of patients due to bradykinin accumulation. May resolve with time or require switching to ARB (angiotensin receptor blocker) if intolerable.
Never double dose: Incorrect and dangerous. If dose is missed, take next scheduled dose at regular time. Doubling doses increases hypotension and hyperkalemia risk.
H5. Prioritization Exercise: Which patient should the nurse assess first?
Heart failure patient: Weight increased 1 kg over 3 days, mild bilateral ankle edema, SpO₂ 94% on room air, no dyspnea at rest
Post-catheterization patient: Stable vital signs 4 hours post-femoral access, requesting assistance with first ambulation
UTI patient: On day 2 of antibiotics, afebrile, asking questions about discharge planning and home medication schedule
Atrial fibrillation patient: Heart rate 150 bpm, blood pressure 96/58 mm Hg, reports new-onset dizziness when standing
Rationale
Patient #4 requires immediate assessment due to hemodynamic instability from uncontrolled atrial fibrillation.
Critical findings in Patient #4:
Heart rate 150 bpm with AF RVR indicates inadequate rate control
Blood pressure 96/58 mm Hg suggests borderline hypotension from reduced cardiac output
Dizziness indicates cerebral hypoperfusion and syncope risk
High risk for hemodynamic collapse requiring urgent intervention
Priority rationale:
Patient #1: Stable with early fluid retention; requires monitoring and possible diuretic adjustment but not emergent
Patient #2: Stable post-procedure; ambulation assistance can wait briefly
Patient #3: Improving infection; discharge teaching can be delayed
Patient #4: Unstable tachyarrhythmia with hypotension and neurologic symptoms—needs immediate ECG, IV access, rate control medications, and continuous monitoring. May require urgent cardioversion if unstable.
Use ABC priority framework: Airway, Breathing, Circulation. Patient #4 has circulation compromise requiring immediate intervention to prevent deterioration.
Practice Performance Summary
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