A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?.
Weight increase from 120 pounds to 122 pounds over 3 days.
Serum potassium level 3.0 mEq/L after 1 week of therapy.
Palpable liver edge 2 cm below the ribs on the right side.
Presence of 1+ to 2+ edema in the feet and ankles.
The Correct Answer is B
Choice A rationale:
A weight increase from 120 pounds to 122 pounds over 3 days is within the normal fluctuation range.
Choice B rationale:
A serum potassium level of 3.0 mEq/L after 1 week of therapy is concerning because it’s below the normal range (3.5-5.0 mEq/L)171819. This could indicate hypokalemia, which can cause serious complications if left untreated.
Choice C rationale:
A palpable liver edge 2 cm below the ribs on the right side could suggest an abnormality such as an enlarged liver.
Choice D rationale:
The presence of 1+ to 2+ edema in the feet and ankles could indicate conditions like heart failure or venous insufficiency.
So, the correct answer is Choice B, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A rationale:
Dependent rubor refers to redness of the skin that occurs when the leg is in a dependent (hanging down) position. It is often associated with peripheral artery disease. However, the child’s symptoms do not indicate this condition.
Choice B rationale:
Digitalis toxicity can occur as a result of high levels of the drug digoxin. Symptoms can include nausea, vomiting, weakness, and vision changes. Given that the child has been administered digoxin, there is a risk for this condition.
Choice C rationale:
Carditis is inflammation of the heart or its surroundings. It is usually caused by bacterial or viral infections. The child’s symptoms do not suggest an infection, making this choice less likely.
Choice D rationale:
Hypercyanotic spells, also known as “tet spells,” are associated with Tetralogy of Fallot, a specific congenital heart defect. The child has a history of congenital mitral stenosis, not Tetralogy of Fallot, making this choice less likely.
Choice E rationale:
Hypokalemia, or low potassium levels, can occur as a side effect of taking diuretics like furosemide. Given that the child has been administered furosemide, there is a risk for this condition.
Choice F rationale:
Fever is usually a response to infection or inflammation. The child’s symptoms do not suggest an infection or inflammation, making this choice less likely.
Choice G rationale:
Hypertension, or high blood pressure, is not indicated in the child’s symptoms or history. The child’s blood pressure readings are within normal range, making this choice less likely.
Choice H rationale:
A murmur is a sound that can be heard when listening to the heart with a stethoscope. It is often caused by turbulent blood flow through the heart. The child’s notes do not mention a murmur, making this choice less likely.
So, the correct answer is, the child is at risk for developing Digitalis toxicity and Hypokalemia. .
Correct Answer is D
Explanation
Choice A rationale:
While aspirin is often given to patients with suspected myocardial infarction, asking if the patient took aspirin does not help determine the timing of the onset of symptoms.
Choice B rationale:
Knowing the patient’s allergies is important for medication safety, but it does not help determine eligibility for thrombolytic therapy.
Choice C rationale:
Rating the pain on a scale helps assess the severity of the pain, but it does not provide information about the timing of the onset of symptoms.
Choice D rationale:
The time of pain onset is crucial in determining eligibility for thrombolytic therapy. Thrombolytic therapy is most effective when given within a certain time frame from the onset of symptoms.
So, the correct answer is D, after analyzing all choices.
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