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 B
Explanation
Chronic stable angina, also known as angina pectoris, is a type of chest pain that occurs when the heart muscle doesn’t get enough oxygen. It is often triggered by physical activity or emotional stress and is usually relieved by rest or medication such as nitroglycerin. Therefore, a patient statement that the pain goes away after taking a nitroglycerin tablet would help confirm a previous diagnosis of chronic stable angina.
Correct Answer is C
Explanation
Choice A rationale
Reducing the overall contractility of the heart muscle is not the primary reason for performing Coronary Artery Bypass Surgery (CABG)4. In fact, reducing the contractility of the heart muscle could potentially decrease the heart’s ability to pump blood effectively.
Choice B rationale
Reducing plaque buildup in the carotid artery is not the primary reason for performing CABG4. While plaque buildup in the carotid artery can lead to serious conditions such as stroke, CABG is specifically performed to bypass blocked coronary arteries, not carotid arteries.
Choice C rationale
Increasing the oxygen supply to the heart muscle is the primary reason for performing CABG4. When coronary arteries become blocked or narrowed due to plaque buildup, the heart muscle may not receive enough oxygen-rich blood. CABG is performed to create a new route, or bypass, around the blocked artery, which improves blood flow and oxygen supply to the heart muscle.
Choice D rationale
Increasing the myocardial workload is not the primary reason for performing CABG4. In fact, increasing the workload of the heart could potentially exacerbate heart disease and lead to complications such as heart failure.
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