A nurse in a clinic is caring for an older adult client.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Atelectasis is incorrect. Atelectasis refers to lung collapse, which presents as reduced breath sounds and hypoxemia, not abnormal chest movement during respiration.
B. Flail chest is correct. Flail chest is characterized by paradoxical chest movement where a segment of the chest wall moves inward during inspiration and outward during expiration.
C. Pneumothorax is incorrect. Pneumothorax would cause sudden chest pain and dyspnea, but does not cause paradoxical chest movement.
D. Hemothorax is incorrect. Hemothorax involves blood in the pleural space and would cause reduced breath sounds and signs of shock, but not paradoxical chest movement.
Correct Answer is B
Explanation
A. The client cannot travel by air due to security screening is incorrect; clients with ICDs can travel by air but should inform security personnel about the ICD.
B. The client should hold his cell phone on the side opposite the ICD to avoid interference with the ICD’s functioning.
C. The client can carry his ICD in a small pocket is incorrect; the ICD is implanted and does not need to be carried.
D. The client should avoid the use of small electric devices is not entirely accurate; the client should follow specific guidelines but not avoid all small devices.
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