A client reports weakness, dizziness, nausea and vomiting that has lasted for three days. The nurse's assessment reveals dry tongue and oral mucosa, and dark concentrated urine. Which additional assessment would best evaluate the client's fluid status?

Respiratory rate and depth

Rectal temperature

Blood pressure lying, sitting and standing

Pulse oximetry reading at rest

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not the best answer. Respiratory rate and depth can indicate the client's oxygenation and ventilation, but not necessarily their fluid status. The client may have normal or increased respiratory rate and depth due to dehydration, acidosis, or anxiety, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's respiratory rate and depth, but also assess other parameters of fluid status.

Choice B reason: This is not the best answer. Rectal temperature can indicate the client's core body temperature, but not necessarily their fluid status. The client may have normal or elevated rectal temperature due to infection, inflammation, or dehydration, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's rectal temperature, but also assess other parameters of fluid status.

Choice C reason: This is the best answer. Blood pressure lying, sitting and standing can indicate the client's fluid status and vascular tone. The client may have low blood pressure due to fluid loss, hypovolemia, or vasodilation, and this can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. The nurse should measure the client's blood pressure in different positions and observe for signs of orthostatic hypotension, such as dizziness, fainting, or blurred vision.

Choice D reason: This is not the best answer. Pulse oximetry reading at rest can indicate the client's oxygen saturation, but not necessarily their fluid status. The client may have normal or decreased pulse oximetry reading due to hypoxia, anemia, or poor peripheral perfusion, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's pulse oximetry reading, but also assess other parameters of fluid status.

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Correct Answer is B

Explanation

Choice A reason: Glucose of 110 mg/dL is not a finding that indicates digoxin toxicity. It is a normal blood glucose level for a fasting or non-fasting client.

Choice B reason: Potassium of 3.0 mEq/L is a finding that indicates digoxin toxicity. It is a low serum potassium level, which increases the risk of digoxin toxicity by enhancing the binding of digoxin to cardiac cells. The nurse should monitor the client for signs and symptoms of digoxin toxicity, such as nausea, vomiting, anorexia, fatigue, confusion, visual disturbances, and cardiac arrhythmias.

Choice C reason: Calcium of 9.0 mg/dL is not a finding that indicates digoxin toxicity. It is a normal serum calcium level for an adult client.

Choice D reason: Sodium of 133 mEq/L is not a finding that indicates digoxin toxicity. It is a slightly low serum sodium level, which may indicate hyponatremia, but not digoxin toxicity.

A. Furosemide 40 mg PO daily B. Diltiazem 30 mg PO daily C. Metoprolol 25 mg PO bid D. Nitroglycerin 0.4 mg SL PRN

Correct Answer is D

Explanation

Choice A reason: Furosemide 40 mg PO daily is not the medication that the nurse should administer for chest pain. Furosemide is a diuretic that reduces fluid volume and lowers blood pressure, but it does not relieve anginal pain.

Choice B reason: Diltiazem 30 mg PO daily is not the medication that the nurse should administer for chest pain. Diltiazem is a calcium channel blocker that relaxes the blood vessels and lowers blood pressure, but it does not act quickly enough to relieve acute anginal pain.

Choice C reason: Metoprolol 25 mg PO bid is not the medication that the nurse should administer for chest pain. Metoprolol is a beta blocker that slows down the heart rate and lowers blood pressure, but it does not act quickly enough to relieve acute anginal pain.

Choice D reason: Nitroglycerin 0.4 mg SL PRN is the medication that the nurse should administer for chest pain. Nitroglycerin is a nitrate that dilates the coronary arteries and increases blood flow to the heart, thus relieving anginal pain. It is given sublingually (under the tongue) as needed for chest pain.

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A client reports weakness, dizziness, nausea and vomiting that has lasted for three days. The nurse's assessment reveals dry tongue and oral mucosa, and dark concentrated urine. Which additional assessment would best evaluate the client's fluid status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should monitor the client for clinical manifestations of digoxin toxicity if the laboratory report reflects a serum:

Correct Answer is B

Explanation

The nurse is providing care for a client diagnosed with cardiovascular disease and hypertension who is complaining of chest pain. Which medication should the nurse administer?

Correct Answer is D

Explanation

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The nurse is reviewing the laboratory test results of a client with long-standing hypertension. Which result would be of most concern to the nurse?

The nurse should teach the client who is taking digoxin 0.125 mg PO daily to call the healthcare provider if which side effect is experienced?

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