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 {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
A. Start an IV bolus of lactated Ringer's solution: Not Indicated
- The client's medical record does not indicate a need for fluid resuscitation or immediate volume replacement.
B. Stay with the client for the first 15 min of the transfusion: Not Indicated
- There is no mention of a blood transfusion in the provided information. Therefore, staying with the client during a transfusion is not relevant.
C. Obtain the first unit of packed RBCs from the blood bank: Not Indicated
- There is no indication of a need for a blood transfusion in the client's assessment findings.
D. Document the blood product transfusion in the client's medical record: Not Indicated
- Since there is no indication of a blood transfusion, documenting a transfusion is not relevant.
E. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: Not Indicated
- While it's important to monitor and maintain the client's blood pressure, the provided information does not suggest that the client's blood pressure is significantly low (90/60 mm Hg) or that they are receiving any infusions that need titration for blood pressure management.
Correct Answer is C
Explanation
A. Waiting for 2 minutes between suctions is a standard practice to prevent damage to the trachea and to allow the client to recover from the suctioning process. This action is also appropriate and does not require intervention.
B. Suction is typically applied for 10-15 seconds while withdrawing the catheter to prevent hypoxia and trauma to the airway.
C. Encouraging a client to cough during suctioning is generally acceptable because coughing helps expel secretions from the airway.However, the nurse should ensure that the client does not cough too forcefully, as this could lead to trauma or discomfort.
D. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.
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