60. A nurse on a medical surgical unit is receiving a client who is postoperative following a laparotomy. In which order should the nurse perform the following actions? (Move the steps, placing them in the order of performance. Use all the steps.)

A. Dependent edema: Dependent edema can indicate fluid retention or right-sided heart failure, which may develop in pericardial disease over time. While important to monitor, it is a later sign and does not reflect the immediate risk of hemodynamic compromise, making it a lower priority in acute assessment.

B. Pericardial friction rub: A friction rub is a classic diagnostic finding in pericarditis and helps confirm inflammation of the pericardium. Although important for diagnosis, it does not indicate immediate life-threatening complications, so it is not the highest priority.

C. Paradoxical pulse: A paradoxical pulse (an exaggerated decrease in systolic blood pressure during inspiration) signals cardiac tamponade, which is a life-threatening complication of pericarditis. Prompt recognition and intervention are critical to prevent cardiovascular collapse, making this the priority finding during assessment.

D. Substernal chest pain: Chest pain is a common symptom of pericarditis and should be assessed and managed for comfort and safety. However, while distressing, it does not indicate imminent cardiovascular compromise, so it is less urgent than a finding that suggests tamponade.

A. "Notify your provider if you experience muscle weakness.": Muscle weakness can be an early sign of hypokalemia, which increases the risk of digoxin toxicity by enhancing the drug’s effects on cardiac tissues. Prompt reporting helps prevent bradyarrhythmias and other serious complications associated with elevated digoxin sensitivity.

B. "Report a weight gain of one-half pound per day.": A gain of 0.5 lb per day is not typically used as a threshold for concern in heart failure management; providers generally focus on gains of 2–3 lb in a day or 5 lb in a week. This small fluctuation is often normal and may simply reflect fluid or dietary changes.

C. "Expect this medication to increase your blood pressure.": Digoxin does not raise blood pressure; its primary action is to improve myocardial contractility and slow heart rate through vagal stimulation. Clients should not expect hypertensive effects, and blood pressure changes are not a primary teaching point.

D. "You will need to take a diuretic while taking this medication.": A diuretic is not automatically required with digoxin because its use depends on the client’s underlying cardiac condition and fluid status. Some diuretics can worsen hypokalemia, increasing the risk for digoxin toxicity, so prescribing them requires careful provider evaluation.