A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?

Reference Range:

Potassium (K+) [3.5 to 5.0mEq/L (3.5 to 5.0 mmol/L)]

Compare the weight with what it was at last visit.

Report serum potassium to healthcare provider.

Review the dietary history from the past week.

Check the pretibial areas and ankles for edema.

Answer and Explanation

The Correct Answer is B

A.   While weight monitoring is important for heart failure management, it's not the priority in this situation. The low potassium level is a more immediate concern.
B.   The serum potassium level of 2.9 mEq/L is significantly below the normal range and indicates hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias, especially in patients taking cardiac glycosides. This is a critical finding that requires immediate attention from the healthcare provider.
C.   Dietary intake can contribute to potassium levels, but it's not the most urgent action at this time.
D.   Assessing for edema is important for monitoring heart failure status, but it's not the priority when there's a critical electrolyte imbalance.

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Correct Answer is C

Explanation

A. Weight lifting can be beneficial for overall fitness, but for someone with chronic venous insufficiency, the focus should be on activities that improve venous return and avoid excessive strain on the legs. Heavy weight lifting might exacerbate symptoms or lead to further complications.
B. For individuals with chronic venous insufficiency, prolonged standing can worsen symptoms such as swelling and pain. It’s important to avoid standing for long periods and to use measures such as leg elevation and compression stockings to manage symptoms.
C. This statement reflects an understanding of good practices for managing chronic venous insufficiency. Sitting for prolonged periods and crossing the legs can impede venous return and worsen symptoms of CVI. It is advised to avoid these practices and instead frequently change positions, elevate the legs, and use compression stockings to improve circulation.
D. While getting help to walk a dog could be beneficial if the client is unable to walk or if walking exacerbates symptoms, this statement does not directly address key aspects of managing chronic venous insufficiency. Regular walking is generally recommended to enhance venous return and prevent complications, assuming it is done within the client’s tolerance and ability.

A. Weight gain. B. Hypoventilation. C. Cold intolerance. D. Lethargy

Correct Answer is B

Explanation

A. Weight gain is a common symptom of hypothyroidism but it is not an immediate threat to life. It can be managed with diet and medication.
B. Hypoventilation, or decreased respiratory rate, can lead to hypoxemia (low oxygen levels in the blood) and hypercapnia (increased carbon dioxide levels in the blood). These conditions can rapidly deteriorate into a respiratory crisis and require immediate intervention.
C. Cold intolerance is a common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with warm clothing and a warm environment.
D. Lethargy is another common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with medication and lifestyle changes.
8. The nurse reviews discharge instructions with a client

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Naxlex Comprehensive Predictor Exams

A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?

Correct Answer is C

Explanation

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Correct Answer is B

Explanation

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