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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The statement “I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart” indicates that the patient understands the correct use of sublingual nitroglycerin (Nitrostat). If chest pain is not relieved after a total of 3 tablets or sprays, this is an emergency situation and medical help should be sought immediately.

A. Trendelenburg position. B. Sims’ position. C. Semi-Fowler’s position. D. Fowler’s position with legs lowered.

Correct Answer is D

Explanation

The symptoms described - tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum - are indicative of acute pulmonary edema, a condition characterized by fluid accumulation in the lungs due to heart failure. In this situation, the Fowler’s position (sitting up at a 45-60 degree angle) with legs lowered is recommended. This position helps to reduce venous return to the heart, thereby decreasing the workload on the heart and helping to alleviate symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patient statement indicates that the nurse’s teaching about sublingual nitroglycerin (Nitrostat) has been effective?

Correct Answer is B

Explanation

A client exhibits tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum. What position should the nurse place the client in?

Correct Answer is D

Explanation

A nurse performs Homans maneuver by flexing the knee and sharply dorsiflexing the foot. What response indicates a positive Homans sign?

For a patient recovering from an acute myocardial infarction (AMI) who inquires about safely resuming sexual intercourse, what would be the best response from the nurse?

When assessing a male patient in the telemetry unit who is experiencing persistent, crushing chest pain, which symptoms would lead the nurse to suspect a myocardial infarction?

A client is admitted to the telemetry unit due to an episode of substernal chest pain. Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level. What would be an appropriate initial nursing intervention?

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After receiving a change-of-shift report, which patient admitted to the emergency department should the nurse assess first?

A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds. Which of the following findings should the nurse be most concerned about?

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