A nurse in a clinic is caring for an older adult client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Digoxin Toxicity: The client’s symptoms (nausea, vomiting, diarrhea, weakness), vital signs (bradycardia), and lab results (high digoxin level, low potassium and magnesium) suggest digoxin toxicity.

Cardiac Monitor: To detect any arrhythmias resulting from digoxin toxicity.

Icterus: To assess liver function, which could be impacted in severe toxicity.

Electrolytes: Imbalances in potassium and magnesium can worsen digoxin toxicity and need to be corrected.

Fever: The fever might indicate an infection or inflammatory process, which can affect treatment and recovery.

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Correct Answer is ["B","C","E"]

Explanation

A. Increase in hematocrit is not expected in fluid overload; it generally decreases due to dilution of blood components.

B. Increased respiratory rate can occur as the body tries to compensate for fluid overload, which may affect lung function and cause respiratory distress.

C. Increased blood pressure is a common finding in fluid overload due to increased blood volume in the circulatory system.

D. Increased temperature is not a typical finding in fluid overload; it might be associated with infection or inflammation instead.

E. Increased heart rate can occur as the body compensates for increased blood volume and higher blood pressure.

A. A Advise the client to place one nitroglycerin tablet under his tongue as a precaution. B. B Tell the client to have someone bring him to an emergency department immediately. C. C Instruct the client to increase his intake of oral fluids until the skin flushing is relieved. D. D Reassure the client that skin flushing is a common side effect of the medication.

Correct Answer is D

Explanation

A. Advise the client to place one nitroglycerin tablet under his tongue as a precaution: Nitroglycerin is contraindicated in combination with phosphodiesterase type 5 inhibitors like tadalafil due to the risk of severe hypotension. This action could worsen the client's condition.
B. Tell the client to have someone bring him to an emergency department immediately: Skin flushing is a common side effect of tadalafil and not necessarily indicative of a medical emergency, especially in the absence of chest pain or other concerning symptoms.
C. Instruct the client to increase his intake of oral fluids until the skin flushing is relieved Increasing fluid intake is not likely to alleviate the skin flushing associated with tadalafil. This response does not address the client's concern adequately.
D. Reassure the client that skin flushing is a common side effect of the medication: Tadalafil, a phosphodiesterase type 5 inhibitor, commonly causes facial flushing as a side effect. Reassuring the client about this known side effect is appropriate, especially since he is not experiencing chest pain or other concerning symptoms.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

Correct Answer is D

Explanation

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