A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Document the findings and continue with the visit.

Notify the RN case manager of the change in status.

Reinforce the importance of daily weights.

Ensure the client has been taking their prescribed diuretic.

Answer and Explanation

The Correct Answer is B

A. Documenting the findings and continuing the visit does not address the potential seriousness of the weight gain and edema in a patient with heart failure. It is important to act promptly on such findings.

B. Notifying the RN case manager of the change in status is essential because a weight gain of this magnitude, along with generalized edema, may indicate worsening heart failure. This requires a timely assessment and possible adjustment of the treatment plan, including medication and fluid management.

C. While reinforcing the importance of daily weights is beneficial for long-term management, it is not an immediate intervention for the acute change in the patient’s condition.

D. Ensuring the client has been taking their prescribed diuretic is important, but the nurse should first communicate the significant changes to the RN case manager for further evaluation and intervention, as this might require a medication review or adjustment.

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Correct Answer is B

Explanation

A. The right groin area is not the site of the procedure, so placing a sandbag here would not help control bleeding or pressure.
B. The sandbag should be placed over the left groin area where the femoral artery was accessed during the angiography. This helps apply pressure to prevent bleeding from the site and promote clot formation.
C. The right ankle is irrelevant to the procedure and would not require pressure.
D. Similarly, the left ankle has no relation to the femoral angiography site.

A. Measure the client's apical pulse rate for 30 seconds before administration. B. Withhold the medication if the client's heart rate is above 100/min. C. Instruct the client to eat foods that are low in potassium. D. Monitor the client for nausea, vomiting, and yellow vision.

Correct Answer is D

Explanation

A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.

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A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client following a left femoral cardiac angiography. The nurse should place a sandbag on the client over which of the following areas?

Correct Answer is B

Explanation

A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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