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A nurse is collecting data from a client prior to the administration of digoxin. Which of the following findings should the nurse report to the provider?

Potassium level of 3.0 mEq/L

Heart rate of 66/min

BP of 132/82 mm Hg

Digoxin level of 1.2 ng/ml

Answer and Explanation

The Correct Answer is A

a. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a

potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.

b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to

treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.

c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.

d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.

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Correct Answer is D

Explanation

A. Inspiratory stridor - This is associated with upper airway obstruction and is not indicative of a pneumothorax.

B. Expiratory wheeze - Wheezing is commonly associated with lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD), not pneumothorax.

C. Coarse crackles - Coarse crackles are typically heard in conditions such as pneumonia or pulmonary edema, not pneumothorax.

D. Absence of breath sounds - This is a key manifestation of a pneumothorax. The air in the pleural space can prevent the lung from fully expanding, leading to the absence of breath sounds on the affected side.

A. Begin oxygen therapy. B. Start an IV infusion of lactated Ringer’s. C. Initiate cardiac monitoring. D. Administer IV morphine.

Correct Answer is A

Explanation

a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.

b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.

c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.

d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.

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A nurse is collecting data from a client prior to the administration of digoxin. Which of the following findings should the nurse report to the provider?

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