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 A

Explanation

Choice A rationale
Skin hyperpigmentation is a common symptom of chronic venous insufficiency. This happens because blood pools in the veins and can leak into the surrounding tissue, causing a change in skin color.
Choice B rationale
Gangrene is not a typical symptom of chronic venous insufficiency. Gangrene is a serious condition that occurs when tissue dies due to a lack of blood flow.
Choice C rationale
Edema, or swelling, is a common symptom of chronic venous insufficiency, but it typically occurs in the lower legs and ankles, not above the knee.
Choice D rationale
Deep vein thrombus formation is not a typical symptom of chronic venous insufficiency. However, a history of deep vein thrombosis can increase the risk of developing chronic venous insufficiency.

A. Redness on both sides of the sternal incision. B. Fine crackles heard at both lung bases. C. Complaints of incisional chest pain. D. Pallor and weakness of the right hand.

Correct Answer is D

Explanation

Choice A rationale
Redness on both sides of the sternal incision could indicate a normal inflammatory response post-surgery or could be a sign of infection. However, it is not the most crucial observation to report in the context of a patient who has undergone coronary artery bypass grafting using a right radial artery graft.
Choice B rationale
Fine crackles heard at both lung bases could indicate fluid accumulation in the lungs, possibly due to heart failure or pneumonia. While this is a significant finding that requires further investigation, it is not the most crucial observation in this specific context.
Choice C rationale
Complaints of incisional chest pain are common after coronary artery bypass grafting. Pain management is an important part of post-operative care, but this symptom is not the most crucial to report in this context.
Choice D rationale
Pallor and weakness of the right hand could indicate compromised blood flow to the hand, which is a serious complication considering the right radial artery was used for the graft. This could lead to ischemia and tissue damage in the hand, thus it is the most crucial observation to report to the healthcare provider.

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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

A 52-year-old male is diagnosed with chronic venous insufficiency, presenting with pooling of blood in the veins of the lower extremities and edema. Which of the following is an expected assessment finding of this disorder?

Correct Answer is A

Explanation

In the context of a patient who has undergone coronary artery bypass grafting using a right radial artery graft, which observation is most crucial for the nurse to report to the healthcare provider?

Correct Answer is D

Explanation

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