A nurse in a clinic is caring for a client who has heart failure and is taking digoxin. Which of the following statements by the client indicates the client is experiencing digoxin toxicity?
“My tongue is red and beefy.”.
“I am constipated.”.
“My vision seems yellow.”.
“I am gaining weight.”.
The Correct Answer is C
Choice A rationale
A red and beefy tongue is not a symptom of digoxin toxicity. This symptom is more commonly associated with vitamin B12 deficiency or other nutritional deficiencies.
Choice B rationale
Constipation is not a typical symptom of digoxin toxicity. Digoxin toxicity primarily affects the gastrointestinal system with symptoms such as nausea, vomiting, and diarrhea, rather than causing constipation.
Choice C rationale
Yellow vision, or xanthopsia, is a classic symptom of digoxin toxicity. Digoxin can cause visual disturbances, including seeing halos around lights and a yellow tint to vision, due to its effects on the optic nerve.
Choice D rationale
Gaining weight is not a symptom of digoxin toxicity. Weight gain is more commonly associated with fluid retention in conditions such as heart failure, which digoxin is used to treat.
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Correct Answer is B
Explanation
Choice A rationale
Notifying the charge nurse is important, but the priority action is to assess the client for any adverse effects of the medication error. This ensures the client’s immediate safety.
Choice B rationale
Checking the client’s vital signs is the priority action because it allows the nurse to assess for any immediate adverse effects of the medication error, such as changes in blood pressure or heart rate.
Choice C rationale
Filling out an occurrence report is necessary for documentation and institutional policy, but it is not the immediate priority. The client’s safety and assessment come first.
Choice D rationale
Documenting an objective description of the event in the client’s chart is important for medical records, but it should be done after assessing the client’s condition.
Correct Answer is B
Explanation
Choice A rationale
Type 2 diabetes is characterized by insulin resistance, not the overproduction of insulin. Over time, the pancreas may produce less insulin, but the primary issue is the body’s inability to use insulin effectively.
Choice B rationale
Type 2 diabetes involves the body’s inability to process glucose properly due to insulin resistance. This leads to elevated blood glucose levels and various complications if not managed effectively.
Choice C rationale
Hemoglobin binding to sugar is related to the measurement of HbA1c, which reflects average blood glucose levels over time. It is not a cause of type 2 diabetes.
Choice D rationale
The destruction of pancreatic cells is a characteristic of type 1 diabetes, an autoimmune condition. Type 2 diabetes is primarily due to insulin resistance and is not caused by an autoimmune response.
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