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 C
Explanation
Choice A rationale
While obesity can contribute to hypertension and other cardiovascular diseases, it is not a contraindication for the use of propranolol. Weight management would be part of the overall treatment plan for hypertension, but it would not prevent the use of this medication.
Choice B rationale
Age is not a contraindication for the use of propranolol. While older adults may be more susceptible to certain side effects of the medication, age alone would not prevent a patient from taking propranolol.
Choice C rationale
Diabetes is a contraindication for the use of propranolol. Propranolol is a non-selective beta- blocker, which can mask symptoms of hypoglycemia, a common condition in people with diabetes. Therefore, it’s generally not recommended for people with diabetes.
Choice D rationale
Race is not a contraindication for the use of propranolol. While there are some differences in how people of different races may respond to certain medications, race alone would not prevent a patient from taking propranolol.
Correct Answer is B
Explanation
Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.
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