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 C
Explanation
Choice A rationale
Bradycardia, palpitations, confusion, and truncal rash are not typically associated with septic shock. Septic shock is a severe infection that occurs when bacteria enter the bloodstream. It can cause organs to fail and can lead to death.
Choice B rationale
Severe respiratory distress, jugular venous distention, and chest pain are more commonly associated with conditions like heart failure or pulmonary embolism, not septic shock.
Choice C rationale
Low blood pressure and tachycardia are common symptoms of septic shock. This happens because the body’s response to the infection causes blood vessels to dilate, which can lower blood pressure. The heart rate often increases (tachycardia) in an attempt to maintain blood flow to the organs.
Choice D rationale
Reduced cardiac output, increased systemic vascular resistance, and a moist cough are not typical symptoms of septic shock. These symptoms are more commonly associated with conditions like heart failure.
Correct Answer is D
Explanation
Choice A rationale
Secondary hypertension is high blood pressure that is caused by another medical condition or medication. It is not the most common type of hypertension.
Choice B rationale
Congenital hypertension is not a recognized type of hypertension. Hypertension can be associated with some congenital conditions, but it is not a type of hypertension itself.
Choice C rationale
Acquired hypertension is not a recognized type of hypertension. While lifestyle factors can contribute to the development of hypertension, the term “acquired hypertension” is not typically used.
Choice D rationale
Primary hypertension, also known as essential hypertension, is the most common type of hypertension. It is high blood pressure that does not have a known secondary cause.
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