A nurse is collecting data from an adolescent client who takes digoxin.
The nurse should monitor the client for which of the following adverse effects?
Yellow Sclera.
Blurred vision.
Frequent swallowing.
Bleeding gums.
The Correct Answer is B
Blurred vision is a common adverse effect of digoxin that affects the eyes and the central nervous system. It can also cause yellow or green vision, halos around lights, and night blindness.
Choice A is wrong because yellow sclera is not an adverse effect of digoxin. It can be a sign of jaundice or liver disease.
Choice C is wrong because frequent swallowing is not an adverse effect of digoxin.
It can be a sign of dysphagia or throat irritation.
Choice D is wrong because bleeding gums is not an adverse effect of digoxin. It can be a sign of gingivitis or coagulation disorder.
Other adverse effects of digoxin include nausea, vomiting, diarrhea, lower stomach pain, dizziness, drowsiness, headache, weakness, confusion, depression, anxiety, hallucinations, expressed fear of impending death, rash, weight loss, loss of appetite, and various cardiac arrhythmias.
Some of these effects can indicate digoxin toxicity and require immediate medical attention.
Normal ranges for serum digoxin levels are 0.5 to 2 ng/mL for adults and 0.8 to 2 ng/mL for children.
Serum digoxin levels should be monitored regularly to avoid overdose or underdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
Choice B is wrong because the task is within the AP’s range of function to perform.
This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
Choice C is wrong because the task can be performed in the same manner for most clients.
This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
Choice D is wrong because the task requires a specific sequence of steps.
This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
Correct Answer is B
Explanation
This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.
Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.
Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.
Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure
condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.
Normal ranges for heart failure clients are:
- Blood pressure: less than 140/90 mmHg
- Heart rate: 60 to 100 beats per minute
- Respiratory rate: 12 to 20 breaths per minute
- Oxygen saturation: greater than 95%
- Weight: stable or decreasing within 2 to 4 pounds per week
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