Choice A Reason:
Visual disturbances is the correct findings. In individuals taking digoxin, visual disturbances such as blurred or yellow-tinted vision can indicate early signs of medication toxicity. This symptom often requires prompt medical attention, as it can precede more severe complications.
Choice B Reason:
Sudden weight gain is not correct. While weight gain can be a symptom of worsening heart failure, it's not typically associated specifically with digoxin toxicity. It's more commonly related to fluid retention in heart failure.
Choice C Reason:
Potassium 4.4 mEq/L is not correct. This potassium level is within the normal range. Digoxin toxicity can be exacerbated by low potassium levels, but a normal potassium level doesn't directly indicate digoxin toxicity.
Choice D Reason:
Insomnia is not a typical early sign of digoxin toxicity. It's more commonly associated with issues like difficulty sleeping rather than being a direct symptom of digoxin toxicity.

Choice A Reason:
Serum osmolarity 310 mOsm/L is incorrect. Serum osmolarity measures the concentration of particles in the blood. While an elevated serum osmolarity might indicate dehydration, it's not a direct indicator of the effectiveness of treatment. It signifies the concentration of solutes in the blood rather than reflecting hydration improvement after treatment.
Choice B Reason:
Serum hematocrit 55%m is incorrect. Elevated hematocrit levels can occur in dehydration because of hemoconcentration (an increase in the concentration of red blood cells due to reduced fluid volume). However, similar to serum osmolarity, while it can indicate dehydration, it doesn't specifically reflect the effectiveness of treatment.
To determine effective treatment of dehydration, the nurse should consider the laboratory values that reflect hydration status:
Choice C Reason:
Urine specific gravity 1.020 is correct. Urine specific gravity measures the concentration of solutes in the urine, indicating the kidneys' ability to concentrate urine. A higher specific gravity (typically above 1.020) suggests more concentrated urine, which can indicate dehydration. As hydration improves, the urine becomes less concentrated, so a decrease in urine specific gravity toward the normal range (around 1.010-1.020) indicates effective rehydration and improved kidney function in retaining fluids.
Choice D Reason:
BUN 28 mg/dL is incorrect. Blood urea nitrogen (BUN) levels can also rise in dehydration due to reduced kidney perfusion. However, like serum osmolarity and hematocrit, while it can indicate dehydration, it doesn't directly show the effectiveness of treatment or the improvement in hydration status after treatment.

Choice A Reason:
Furosemide is not correct. Furosemide is a diuretic used to treat conditions like heart failure and edema by increasing urine output. It is not a contraindication for sildenafil. However, it's essential to monitor blood pressure when these medications are used together, as both can potentially lower blood pressure.
Choice B Reason:
Albuterol is not correct. Albuterol is a bronchodilator commonly used to treat asthma and other respiratory conditions. It doesn't have direct contraindications with sildenafil for erectile dysfunction. Although both medications can cause some cardiovascular effects, they are not typically considered contraindications for each other.
Choice C Reason:
Indomethacin is not correct. Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce inflammation and pain. While it can have effects on blood pressure and the cardiovascular system, it is not a direct contraindication for sildenafil specifically for erectile dysfunction.
Choice D Reason:
Nitroglycerin is correct. Nitroglycerin is a contraindication for sildenafil. Both medications can cause a significant drop in blood pressure. When taken together, they can potentiate each other's effects, leading to a severe decrease in blood pressure, which can be dangerous and potentially life-threatening. Therefore, individuals using nitroglycerin or any nitrate medications should not take sildenafil or other medications for erectile dysfunction due to the risk of hypotension (dangerously low blood pressure).

Choice A Reason:
Determine factors that led to the omission. Understanding why the dosage was missed is crucial. Was there a specific reason such as an interruption, conflicting priorities, or confusion in the medication schedule? Identifying these factors can help prevent future omissions and improve the medication administration process.
Choice B Reason:
File an incident report. If the missed dosage poses any potential risk or deviation from the prescribed treatment plan, it's important to document the incident through an incident report. This ensures transparency and allows the healthcare team to address and learn from the situation.
Choice C Reason:
Report the missed dosage to the client's provider. Informing the client's healthcare provider about the missed dosage is crucial. The provider can assess the situation and provide guidance on whether any adjustments or additional steps are necessary to ensure the client's well-being.
Choice D Reason:
Assess the client for adverse reactions. Monitoring the client for any adverse reactions or changes in their condition is essential after a missed dosage. This observation helps detect any potential effects of the missed medication and allows for prompt intervention if needed.

Choice A Reason:
Weight gain of 0.7 kg (1.5 lb) in 24 hours is not recommendable. While sudden weight gain can indicate fluid retention, it is not a direct contraindication for administering digoxin. However, it might indicate worsening heart failure, which needs attention, but it doesn't specifically necessitate withholding digoxin.
Choice B Reason:
Urinary output 30 mL/hr is not recommendable. A low urinary output might indicate decreased kidney perfusion or renal issues. While monitoring urinary output is important, it is not a direct reason to withhold digoxin unless it's coupled with severe renal impairment or an acute kidney injury.
For a client receiving digoxin, certain findings would warrant withholding the medication due to potential complications. Among the options provided:
Choice C Reason:
Pulse rate 56/min is the correct recommendation. A low pulse rate (bradycardia), especially below 60 beats per minute, is a reason to withhold digoxin. Digoxin can further decrease the heart rate, potentially leading to excessive bradycardia or heart block. The nurse should hold the medication and consult with the healthcare provider to determine the appropriate action.
Choice D Reason:
BP 160/90 mm Hg is not recommendable. Elevated blood pressure alone is not a direct contraindication for administering digoxin to a patient with heart failure. Digoxin is not primarily used for controlling blood pressure; its use is more focused on managing heart rate and contractility in heart failure patients.

Choice A Reason:
"I should avoid drinking grapefruit juice." This statement is actually accurate. Grapefruit juice can interfere with the metabolism of certain statin medications, including lovastatin, leading to increased levels of the drug in the body. Advising against grapefruit juice consumption is a recommended precaution when taking lovastatin, so this statement shows the client's understanding of this interaction.
Choice B Reason:
"I am trying to decrease my dietary fat intake." This statement reflects a positive lifestyle change. Lowering dietary fat intake is often recommended for individuals on statin medications to help manage cholesterol levels. This statement demonstrates the client's commitment to making healthy dietary adjustments, which aligns with the treatment plan.
Choice B Reason:
"I was just diagnosed with hepatitis B. "Hepatitis B can affect liver function, and statin medications like lovastatin can potentially impact liver enzymes. Therefore, in someone with a history of hepatitis B, it's crucial to assess liver function before starting a statin and to monitor the liver during treatment. This statement raises concerns about potential liver complications or interactions that require further evaluation before initiating lovastatin.
Choice D Reason:
"I take metformin for my diabetes." Metformin, a medication for diabetes, does not directly interact with lovastatin. While it's relevant to know the client's other medications, this statement doesn't indicate a need for immediate further assessment regarding the use of lovastatin.

Choice A Reason:
Bilateral muscle weakness is not typically associated specifically with fluid volume excess. Muscle weakness can result from various causes, such as electrolyte imbalances or certain medical conditions, but it's not a primary manifestation of fluid volume excess.
Choice B Reason:
Thready pulse is not correct. A thready pulse refers to a weak and barely palpable pulse. This is more commonly associated with conditions like shock or reduced cardiac output rather than fluid volume excess.
Choice C Reason:
Decreased bowel sounds is not correct. Reduced or absent bowel sounds may indicate gastrointestinal issues, but they are not a direct manifestation of fluid volume excess. Increased bowel sounds might be more associated with certain types of gastrointestinal disturbances or fluid imbalances, but decreased sounds are not a typical sign of fluid volume excess.
Choice D Reason:
Distended neck veins is correct. In a client experiencing fluid volume excess, distended neck veins can often be observed due to increased venous pressure. This occurs as a result of the body retaining more fluid than it can handle, leading to an increase in blood volume and pressure within the vascular system. This can cause the jugular veins in the neck to appear distended or prominent.

Choice A Reason:
There's no requirement to lie down for an hour after administering nasal cyanocobalamin.
Choice B Reason:
The duration of treatment might vary depending on the healthcare provider's instructions and the client's response, so stating a specific duration of 6 months may not be accurate.
Choice C Reason:
"Administer the medication into one nostril once per week. “Nasal cyanocobalamin is typically used weekly for the treatment of pernicious anemia. It's administered into one nostril as directed by a healthcare provider. This method allows for the absorption of vitamin B12 through the nasal mucosa.
Choice D Reason:
Using a nasal decongestant before administering the medication is not typically part of the recommended administration protocol for nasal cyanocobalamin.

Choice A Reason:
Increase in serum glucose is incorrect. Desmopressin, which is a synthetic form of vasopressin, primarily affects water reabsorption in the kidneys and doesn't directly impact glucose levels. Therefore, an increase in serum glucose wouldn't be an expected therapeutic response to desmopressin for diabetes insipidus.
Choice B Reason:
Decrease in blood pressure is incorrect. Desmopressin is primarily used for its antidiuretic effect, concentrating urine by increasing water reabsorption in the kidneys. It typically doesn't have a significant impact on blood pressure. Therefore, a decrease in blood pressure wouldn't typically be an anticipated therapeutic response to desmopressin in this context.
Choice C Reason:
Decrease in urine output is correct. Desmopressin is a synthetic form of vasopressin (antidiuretic hormone) used to treat diabetes insipidus, a condition characterized by excessive urination and extreme thirst due to the inability to concentrate urine. The primary goal of desmopressin is to reduce urine output by increasing water reabsorption in the kidneys, thereby decreasing excessive urination. Therefore, a decrease in urine output would indicate a therapeutic response to the medication in this context.
Choice D Reason:
Increase in WBC count is incorrect. Desmopressin's action is centered on affecting kidney function by regulating water reabsorption and does not involve changes in white blood cell count. Consequently, an increase in WBC count wouldn't be an expected therapeutic response to desmopressin for diabetes insipidus.

Choice A Reason:
Blood pressure is correct. Nitroprusside is a medication used to lower blood pressure in conditions such as hypertensive emergencies. It's titrated based on blood pressure readings, with the goal of achieving the desired target blood pressure range as directed by the healthcare provider. The nurse would monitor the client's blood pressure closely and adjust the infusion rate accordingly to achieve the prescribed blood pressure parameters.
Choice B Reason:
Stroke volume is incorrect. While stroke volume (the amount of blood ejected by the heart with each contraction) is important in assessing heart function, it's not directly used to titrate a nitroprusside infusion. Nitroprusside primarily acts as a vasodilator to reduce blood pressure, rather than affecting stroke volume.
Choice C Reason:
Cardiac output is incorrect. Cardiac output (the volume of blood pumped by the heart per minute) is also a crucial measure of heart function, but adjusting a nitroprusside infusion based on cardiac output is not a common practice. Nitroprusside's primary action is to dilate blood vessels, impacting blood pressure regulation more directly than cardiac output.
Choice D Reason:
Urine output is incorrect. While urine output is an important indicator of renal function and overall fluid balance, it is not typically used as the main parameter for titrating nitroprusside. Nitroprusside's primary effect is on vasodilation and blood pressure control rather than directly impacting urine output.