A patient with heart failure has recently started taking Digoxin (Lanoxin), Furosemide (Lasix), and Captopril. Which finding by the home health nurse is a priority to communicate to the healthcare provider?
Palpable liver edge 2 cm below the ribs on the right side.
Serum potassium level of 3.0 mEq/L after 1 week of therapy.
Weight increase from 120 pounds to 122 pounds over 3 days.
Presence of 1+ to 2+ edema in the feet and ankles.
The Correct Answer is B
Choice A rationale
While palpating the liver edge can provide information about liver health and potential fluid accumulation, it is not typically a priority assessment for a patient taking Digoxin (Lanoxin), Furosemide (Lasix), and Captopril.
Choice B rationale
A serum potassium level of 3.0 mEq/L is low (hypokalemia). This is a critical finding because both Digoxin and Furosemide can cause hypokalemia. Hypokalemia increases the risk of digoxin toxicity, which can lead to serious cardiac arrhythmias.
Choice C rationale
While weight gain may indicate worsening heart failure, a gain of 2 pounds over 3 days is not typically considered significant. However, any sudden or unexplained weight gain should be reported to the healthcare provider.
Choice D rationale
Presence of 1+ to 2+ edema in the feet and ankles could indicate worsening heart failure, but it is not as immediately concerning as hypokalemia in a patient taking Digoxin and Furosemide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac. This procedure can be used to relieve pressure on the heart caused by a large pericardial effusion.
Choice B rationale
A pericardiectomy is a surgical procedure that removes part or all of the pericardium. It is typically used to treat constrictive pericarditis, not pericardial effusion.
Choice C rationale
Heart catheterization involves inserting a long, thin tube (catheter) into a blood vessel and guiding it to the heart. It is typically used to diagnose and treat certain cardiovascular conditions, not pericardial effusion.
Choice D rationale
A thoracotomy is a surgical procedure to gain access to the chest. It is typically used for lung, esophagus, or other chest organ operations, not pericardial effusion.
Correct Answer is A
Explanation
Choice A rationale
Stable angina typically occurs with exertion and goes away with rest. The symptoms described, including substernal pain, discomfort in the left shoulder and jaw, which subside with rest, are characteristic of stable angina.
Choice B rationale
Prinzmetal angina, also known as variant angina, is a type of angina (chest pain) caused by spasms in the coronary arteries. These spasms occur most often in coronary arteries that have not become hardened due to plaque buildup. However, they can also occur in hardened arteries. The symptoms can be similar to those of stable angina, but the typical triggers for the episodes are different.
Choice C rationale
A myocardial infarction (MI), or heart attack, occurs when one of the coronary arteries becomes blocked, often by a blood clot, causing part of the heart muscle to be damaged or die. The symptoms are usually more severe than what is described and do not typically subside with rest.
Choice D rationale
Unstable angina is a condition in which the angina symptoms become more severe, occur more frequently, or occur at rest. This is a medical emergency as it can often lead to a heart attack.
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