Patient Data

Exhibits

Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)

Rationale for correct choices:

• Increase your water and fiber intake while taking opioids: Opioids frequently cause constipation by slowing gastrointestinal motility. Encouraging adequate hydration and fiber intake helps prevent constipation and maintain bowel regularity, which is an essential part of opioid education.

• Expect the morphine to take 1 to 2 hours for full effect: IV morphine typically takes effect within 5 to 10 minutes, with peak analgesic effect in about 20 minutes. Telling the client it takes 1 to 2 hours may cause confusion and unnecessary delay in using other comfort measures.

• Request pain medication only if pain is severe: Waiting until pain is severe can result in poor pain control and decreased participation in respiratory exercises. Encouraging timely administration before pain becomes severe promotes better analgesia and facilitates lung expansion.

• Use incentive spirometer when the pain medication takes effect: Pain can limit the client’s ability to perform deep breathing exercises. Using the incentive spirometer when analgesia is effective promotes lung expansion, reduces atelectasis risk, and improves oxygenation in clients with rib fractures.

• Ask for assistance when getting out of bed after taking morphine: Morphine can cause dizziness, orthostatic hypotension, or sedation, increasing fall risk. Asking for assistance ensures client safety during ambulation or position changes, especially in older adults with recent trauma.

Rationale for correct choices:

• Cellulitis: The client presents with redness, warmth, swelling, and pain in the left lower leg, along with a small preceding cut. These findings are characteristic of cellulitis, a bacterial infection of the dermis and subcutaneous tissue, often following a breach in the skin barrier.

• Break in skin: The small cut noted above the lateral ankle provides an entry point for bacteria, explaining the localized infection. A break in skin is a common precursor to cellulitis, particularly in clients with diabetes or vascular compromise.

• Left lower leg erythema: Erythema indicates inflammation and infection, which are hallmark signs of cellulitis. The presence of erythema, along with swelling and warmth, supports the clinical diagnosis of a bacterial skin infection.

Rationale for incorrect choices:

• Left lower leg erythema (as a diagnosis option): Erythema alone describes a symptom rather than a medical diagnosis. While present, it does not capture the underlying bacterial infection requiring treatment.

• Break in skin (as a diagnosis option): A break in the skin is a risk factor or contributing event, not a formal diagnosis. It explains how infection occurred but does not replace the clinical diagnosis of cellulitis.

• Cool, pale left leg: This finding is more indicative of arterial insufficiency or ischemia rather than infection. The client’s affected leg is warm and erythematous, which contrasts with cool, pale tissue.

• Intact skin: Intact skin would not allow bacterial entry and does not explain the localized infection. The client has a visible small cut that preceded the erythema.

• Dry scaly skin: While common in peripheral vascular disease or chronic dermatologic conditions, dry scaly skin does not explain the acute signs of infection seen in this client.