Based on a client’s serum digoxin level, the client is diagnosed with digoxin toxicity. Which action should the nurse expect to implement?

Administer potassium to stabilize the heart rate.

Begin cardioversion to stabilize heart rhythm.

Check acid-base and electrolyte values.

Give digoxin by another route to slow absorption.

Answer and Explanation

The Correct Answer is C

Choice A reason: Administering potassium is not the primary action for treating digoxin toxicity. While hypokalemia can exacerbate digoxin toxicity, the initial step is to assess and stabilize the patient’s overall condition, including acid-base and electrolyte balance. Potassium administration may be considered if hypokalemia is present, but it is not the first-line treatment.

Choice B reason: Cardioversion is not typically used to treat digoxin toxicity. Digoxin toxicity can cause various arrhythmias, but the treatment focuses on stabilizing the patient and addressing the toxicity itself2. Cardioversion may be considered in life-threatening arrhythmias, but it is not the primary intervention.

Choice C reason: Checking acid-base and electrolyte values is crucial in managing digoxin toxicity. Digoxin toxicity can lead to electrolyte imbalances, particularly hyperkalemia, which can be life-threatening. Assessing and correcting these imbalances is essential for stabilizing the patient and preventing further complications.

Choice D reason: Giving digoxin by another route to slow absorption is not an appropriate action. The primary treatment for digoxin toxicity involves stopping the medication and administering digoxin-specific antibody fragments (Fab) if necessary. These antibodies bind to digoxin, neutralizing its effects and allowing for its excretion.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A"]

Explanation

Choice A reason:

Heart sounds: Monitoring heart sounds is crucial for evaluating the effectiveness of medications in a client with heart failure and coronary artery disease. Changes in heart sounds, such as the presence of new murmurs or gallops, can indicate worsening heart failure or other cardiac complications1. Regular assessment helps in early detection and management of potential issues.

Choice B reason:

Blood pressure: Blood pressure monitoring is essential for clients with hypertension and those taking medications like atenolol and enalapril. These medications are used to manage blood pressure and reduce the workload on the heart. Regular monitoring ensures that the medications are effectively controlling blood pressure within the target range, typically less than 130/80 mm Hg.

Choice C reason:

Bowel sounds: While assessing bowel sounds is important for overall health, it is not directly related to evaluating the effectiveness of heart failure, CAD, or hypertension medications. Bowel sounds are more relevant in gastrointestinal assessments and do not provide specific information about the effectiveness of the prescribed cardiac medications.

Choice D reason:

Daily weight: Monitoring daily weight is a key assessment for clients with heart failure. Sudden weight gain can indicate fluid retention, which is a sign of worsening heart failure. Furosemide, a diuretic, helps manage fluid balance, and daily weight monitoring helps evaluate its effectiveness in preventing fluid overload.

Choice E reason:

Range of motion: Assessing range of motion is important for overall mobility and physical health but is not directly related to evaluating the effectiveness of medications for heart failure, CAD, or hypertension. It is more relevant in musculoskeletal assessments and rehabilitation.

A. Assess the client’s strength in moving and turning in the bed. B. Determine the frequency and consistency of bowel movements. C. Observe the skin integrity of the client’s rectal and sacral areas. D. Evaluate the client’s ability to recognize the urge to defecate.

Correct Answer is B

Explanation

Choice A reason: Assessing the client’s strength in moving and turning in bed is important for overall care, but it is not the primary assessment needed before administering a laxative. This assessment helps in understanding the client’s mobility and risk of pressure ulcers but does not directly relate to the effectiveness or necessity of a laxative.

Choice B reason: Determining the frequency and consistency of bowel movements is crucial before administering a laxative. This assessment provides information on the client’s current bowel function and helps in deciding the appropriate type and dosage of laxative. It ensures that the laxative is necessary and helps prevent complications such as diarrhea or bowel obstruction.

Choice C reason: Observing the skin integrity of the client’s rectal and sacral areas is important for preventing pressure ulcers and maintaining skin health, especially in bedfast clients. However, this assessment is not directly related to the administration of a laxative. It is more relevant to overall skin care and prevention of pressure sores.

Choice D reason: Evaluating the client’s ability to recognize the urge to defecate is important for understanding their bowel habits and potential issues with incontinence. However, it is not the primary assessment needed before administering a laxative. This assessment is more relevant to managing bowel training and incontinence.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Based on a client’s serum digoxin level, the client is diagnosed with digoxin toxicity. Which action should the nurse expect to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN) is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.)

Correct Answer is ["A"]

Explanation

Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Correct Answer is B

Explanation

A client with cystitis receives a prescription for phenazopyridine. Which information should the nurse explain to the client about its therapeutic effect?

When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client’s upper back and the client denies pain. Which action should the nurse take?

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow-up by the nurse?

A female client who is starting a new prescription for doxycycline hyclate tells the nurse that she takes birth control pills. Which action should the nurse take?

Administer a scheduled dose of labetalol PO to a client with hypertension. The client’s temperature is 99°F (37.2°C), a heart rate of 48 beats per minute, respirations of 16 breaths per minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?

The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?

The nurse is providing discharge instructions for a client with metastatic cancer who is prescribed morphine for bone pain. Which information from the client indicates to the nurse an understanding of the medication?

A client who has been experiencing headaches since using the herbal remedy feverfew. Which information is important to include for this client?