Editing Medical-Surgical Nursing – RN Practice Questions (section)

==Question 3==
A nurse is caring for a patient admitted with an exacerbation of heart failure. Which findings should the nurse report to the provider immediately? '''Select all that apply.'''
# Weight gain of 4 pounds since yesterday.
# Pink frothy sputum with new crackles throughout both lung fields.
# Trace bilateral ankle edema that has been present for months.
# Oxygen saturation that has fallen from 95 percent to 86 percent on room air.
# Serum potassium of 2.9 mEq/L in a patient receiving furosemide.

'''Answer:''' Options 1, 2, 4, and 5.

''Rationale:'' A gain of two to three pounds in a day signals acute fluid retention and decompensation. Pink frothy sputum with diffuse crackles indicates acute pulmonary edema, an emergency. A saturation falling to 86 percent is significant hypoxemia. A potassium of 2.9 mEq/L is dangerously low, predisposes to lethal dysrhythmias, and increases digoxin toxicity risk if digoxin is prescribed. Option 3 is a chronic, stable, expected finding in heart failure and does not require immediate notification.