A patient is ordered to receive digoxin to treat congestive heart failure. The nurse is most concerned about which assessment finding.
RR 18 bpm
1+ pitting edema of the lower extremities
BP 138/90 mm Hg
Heart rate 54 beats/min
The Correct Answer is D
A) RR 18 bpm:
A respiratory rate of 18 breaths per minute is within the normal range for adults (12-20 bpm). Therefore, this finding does not pose a significant concern in the context of digoxin therapy. Respiratory rate should be monitored, especially if the patient is experiencing signs of heart failure or digoxin toxicity, but 18 bpm alone is not alarming.
B) 1+ pitting edema of the lower extremities:
Pitting edema, especially with a grade of 1+ (slight indentation), is a common finding in patients with congestive heart failure (CHF). It indicates fluid retention due to the heart's inability to pump blood effectively. While edema should be monitored, it is not immediately life-threatening or specific to digoxin toxicity.
C) BP 138/90 mm Hg:
A blood pressure of 138/90 mm Hg is slightly elevated, but it is not excessively high. This finding is manageable and should be monitored, particularly in heart failure patients, but it does not present an immediate concern in this case. Blood pressure management is crucial in CHF, but it does not directly correlate with digoxin toxicity.
D) Heart rate 54 beats/min:
A heart rate of 54 beats per minute is considered bradycardic, especially in a patient taking digoxin. Digoxin can lower heart rate by increasing vagal tone and inhibiting the AV node. Bradycardia is a well-known sign of digoxin toxicity, and this finding is concerning because it may indicate that the patient is experiencing toxicity. Digoxin-induced bradycardia can lead to more serious arrhythmias or hemodynamic instability, making this the most concerning finding that requires immediate assessment and possibly intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A) Vomiting:
Vomiting is a common symptom of digoxin toxicity. It occurs as a result of the toxic effects of digoxin on the gastrointestinal system. It is often one of the first symptoms that precede more severe signs of toxicity, such as arrhythmias and changes in vision. Vomiting, nausea, and anorexia are classic early signs of digoxin toxicity.
B) Nausea:
Nausea is another early sign of digoxin toxicity. It occurs due to the direct effects of the drug on the gastrointestinal tract and the central nervous system. Along with vomiting, nausea is a frequently observed symptom and often occurs before more severe manifestations like arrhythmias or confusion.
C) Blurred Vision:
Blurred vision, or seeing yellow or green halos around lights, is a hallmark sign of digoxin toxicity. This visual disturbance occurs due to the effect of digoxin on the optic nerve and the retina. This symptom is particularly important in identifying digoxin toxicity, as it is not commonly seen in other conditions.
D) Headache:
While headache may occur in a variety of clinical conditions, it is not typically a direct symptom of digoxin toxicity. Although some patients may experience headache due to general discomfort or the effects of vomiting and nausea, it is not a classic or primary indicator of digoxin toxicity. Therefore, headache is not as strongly associated with digoxin toxicity as vomiting, nausea, and blurred vision are.
E) Muscle aches:
Muscle aches are not a typical symptom of digoxin toxicity. While generalized weakness may occur due to the cardiac effects of digoxin, muscle aches are not specifically associated with toxicity.
Correct Answer is D
Explanation
Given:
Volume of fluid: 50 mL (DSW) + 10 mL (for reconstitution) = 60 mL
Infusion time: 45 minutes
Drop factor: 10 gtt/mL
Formula:
Flow rate (gtt/min) = (Volume (mL) / Time (min)) x Drop factor (gtt/mL)
Step 1: Calculate the infusion rate in mL/min:
Infusion rate (mL/min) = Volume (mL) / Time (min)
Infusion rate (mL/min) = 60 mL / 45 min
Infusion rate (mL/min) = 1.33 mL/min
Step 2: Calculate the flow rate in gtt/min:
Flow rate (gtt/min) = Infusion rate (mL/min) x Drop factor (gtt/mL)
Flow rate (gtt/min) = 1.33 mL/min x 10 gtt/mL
Flow rate (gtt/min) = 13.3 gtt/min
Step 3: Round to the nearest whole number:
Flow rate (gtt/min) ≈ 13 gtt/min
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