A nurse is assessing a client who has prescription for digoxin for congestive heart failure. Which of the following findings should the nurse identify as a manifestation of digoxin toxicity?
Dry mucus membranes
Heart rate 62/min
Hypertension
Client reports yellow-tinged vision
The Correct Answer is D
A. Dry mucus membranes: Dry mouth or dehydration can occur with many conditions or medications, but it is not a characteristic sign of digoxin toxicity. It is unrelated to digoxin’s effects on the heart or vision.
B. Heart rate 62/min: A heart rate of 62/min may be normal for many adults and does not automatically indicate digoxin toxicity. Toxicity more commonly presents with bradycardia below the client’s baseline or with irregular rhythms.
C. Hypertension: Digoxin primarily affects cardiac contractility and conduction rather than blood pressure. Hypertension is not typically associated with digoxin toxicity.
D. Client reports yellow-tinged vision: Visual disturbances such as yellow or green halos around objects, blurred vision, or changes in color perception are classic manifestations of digoxin toxicity. These symptoms occur due to digoxin’s effect on retinal photoreceptors and are important early indicators for intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Decreased blood pressure: While furosemide can lower blood pressure due to fluid loss, the primary therapeutic goal in heart failure is the reduction of fluid overload and improvement in symptoms of congestion, not just lowering BP.
B. Distended neck veins: Jugular vein distention indicates fluid retention and right-sided heart failure, suggesting the medication is not achieving its intended diuretic effect.
C. Weight loss: Furosemide promotes diuresis, reducing excess fluid and relieving edema. Weight loss reflects decreased fluid retention and is a key indicator of therapeutic effectiveness in managing heart failure.
D. Increased heart rate: A rising heart rate may signal worsening heart failure or dehydration from over-diuresis, both of which indicate that the medication is not being tolerated or is not properly balanced.
Correct Answer is C
Explanation
A. Increased bowel sounds: Increased bowel sounds are not associated with IV fluid therapy. They typically occur with gastrointestinal stimulation or diarrhea, not with excessive fluid administration.
B. Dark amber urine: Dark urine indicates concentrated urine and dehydration, suggesting that the client may still be underhydrated rather than experiencing an adverse effect of fluid infusion.
C. Shortness of breath: Shortness of breath can indicate fluid volume overload, an adverse effect of rapid or excessive infusion of 0.9% sodium chloride. The fluid may accumulate in the lungs, leading to pulmonary edema and impaired gas exchange.
D. Decreased skin turgor: Decreased skin turgor is a sign of dehydration, which should improve—not worsen—during IV fluid therapy. Its presence would suggest inadequate fluid replacement rather than an adverse effect.
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