A nurse is assessing a client who has hypercholesterolemia and is receiving simvastatin. Which of the following findings should the nurse recognize as a potential adverse effect?

The Correct answer is A.

Choice A reason: Evaluating the client for nausea, vomiting, and anorexia is important because these are common signs of digoxin toxicity. Digoxin is a cardiac glycoside used to treat heart failure and certain arrhythmias, but it has a narrow therapeutic window. Toxicity can occur due to various factors, including renal insufficiency or drug interactions. Monitoring gastrointestinal symptoms like nausea, vomiting, and loss of appetite can help detect toxicity early.

Choice B reason: Withholding digoxin if the heart rate is above 100/min is not typically recommended. Digoxin has a negative chronotropic effect, meaning it can decrease heart rate. However, the decision to withhold medication usually depends on a heart rate that is too low (bradycardia), not high. The normal range for resting heart rate in adults is 60-100 beats per minute. Therefore, withholding digoxin for a heart rate above 100/min without other clinical justifications would not be appropriate.

Choice C reason: Measuring the apical pulse rate for 30 seconds before administration is not the standard practice. The apical pulse should be measured for a full minute to ensure accuracy, especially in clients with heart failure who are receiving digoxin. This is because digoxin can cause arrhythmias, and a shorter measurement period may not provide a true representation of the heart's rhythm.

Choice D reason: Instructing the client to eat foods that are low in potassium is incorrect. Clients taking digoxin should maintain a normal potassium level, as hypokalemia can increase the risk of digoxin toxicity. The normal serum potassium level is 3.5-5.0 mEq/L. Foods high in potassium can help maintain this balance and should not be avoided unless there is a specific clinical indication, such as hyperkalemia.

Choice A reason: Ataxia is not a manifestation of digoxin toxicity, as it does not affect the coordination or balance of the client. Ataxia may be caused by other factors, such as cerebellar disorders, alcohol intoxication, or medication interactions.

Choice B reason: Anorexia is a manifestation of digoxin toxicity, as it affects the appetite and digestion of the client. Anorexia may be accompanied by nausea, vomiting, or abdominal pain, which are also signs of digoxin toxicity. Anorexia may lead to weight loss, dehydration, or electrolyte imbalance, which can worsen the condition of the client.

Choice C reason: Photosensitivity is not a manifestation of digoxin toxicity, as it does not affect the skin or the eyes of the client. Photosensitivity may be caused by other factors, such as sun exposure, allergies, or medication interactions.

Choice D reason: Jaundice is not a manifestation of digoxin toxicity, as it does not affect the liver or the bilirubin level of the client. Jaundice may be caused by other factors, such as liver disease, gallstones, or hemolysis.