A nurse is assessing a client who is taking digoxin to treat chronic heart failure.
Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?
Hearing loss.
Tachycardia.
Blurred vision.
Insomnia.
The Correct Answer is C
Choice A rationale:
Hearing loss is not a typical sign of digoxin toxicity. Digoxin toxicity primarily affects the visual system, leading to disturbances such as blurred or yellow-tinted vision. It can also cause various cardiac symptoms due to its effects on heart rhythm and contractility. Hearing loss is not a recognized symptom of digoxin toxicity.
Choice B rationale:
Tachycardia (fast heart rate) can be a sign of digoxin toxicity. Digoxin can cause arrhythmias and alter heart rate, which may lead to tachycardia. While this is a possible symptom, it is not as specific as other manifestations, such as visual disturbances.
Choice C rationale:
Blurred vision is a hallmark sign of digoxin toxicity. Digoxin can cause disturbances in color vision, such as seeing yellow or green halos around objects. Blurred vision is a significant indicator of digoxin toxicity and requires prompt medical attention.
Choice D rationale:
Insomnia is not a recognized symptom of digoxin toxicity. Digoxin toxicity primarily affects the cardiovascular and visual systems, leading to symptoms related to heart rhythm disturbances and vision changes. Insomnia is not a typical manifestation of digoxin toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Securing the tracheostomy tube with ties is important, but this is a task that should be performed by healthcare professionals initially. It is not typically part of discharge teaching.
B. Incorrect. Changing the tracheostomy dressing using clean technique is also an essential skill but may not be suitable for discharge teaching. The partner should be educated on monitoring the stoma site and recognizing signs of infection or complications.
C. Correct. Teaching the partner how to operate the portable suction machine is crucial for maintaining a patent airway. Suctioning is often necessary to clear mucus and secretions from the tracheostomy tube, especially when the client is at home.
D. Incorrect. Changing a tracheostomy tube, particularly a nondisposable one, is a procedure that should be performed by healthcare professionals due to the risk of complications and the need for sterile technique. It is not typically part of discharge teaching to non-medical caregivers.
Correct Answer is B
Explanation
A. Cyanosis, a bluish discoloration of the skin, may be more visible in areas where the skin is thinner. The sacrum is not reliable especially in the dark colored individuals.
B. Palms of the hand is reliable site for assessing for cyanosis.
C. Incorrect. Shoulders are not a common location to assess for cyanosis. Areas with thinner skin, such as the lips, oral mucosa, and nail beds, are usually observed for cyanosis.
D. Incorrect. Areas of trauma are not specifically used to assess for cyanosis. Cyanosis is a clinical sign that indicates inadequate oxygenation of the blood.
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