The nurse assesses a client who is prescribed digoxin. The client reports nausea and seeing green halos. Which action should the nurse perform?
Administer the dose later in the day when their nausea subsides
Assess the client's apical rate
Contact the physician for STAT serum potassium level
Administer the client's prescribed dose intravenously
The Correct Answer is B
A. Administer the dose later in the day when their nausea subsides: Delaying the dose does not address the underlying concern of potential digoxin toxicity. Symptoms like nausea and visual disturbances suggest toxicity and require immediate assessment rather than postponement.
B. Assess the client's apical rate: The first and most appropriate nursing action is to assess the apical heart rate for one full minute, as bradycardia is a key indicator of digoxin toxicity. If the rate is below 60 bpm, the dose should be held, and the provider should be notified.
C. Contact the physician for STAT serum potassium level: Hypokalemia increases the risk of digoxin toxicity, but while checking potassium is important, it is not the first step. Assessment of heart rate is more immediately critical in evaluating the need to hold the medication.
D. Administer the client's prescribed dose intravenously: Administering the dose especially IV when the client has symptoms of toxicity could worsen the situation. Digoxin should be held, not given, until further evaluation and provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ensure all tubing connections are tightened: Tight tubing connections are critical in preventing accidental disconnection, which can result in rapid blood loss and air embolism. Arterial lines are under high pressure, so securing all connections is a top priority to ensure patient safety and maintain line integrity.
B. Apply a pressure dressing to the insertion site: A transparent occlusive dressing not a pressure dressing is used for arterial lines to allow for site visualization and reduce the risk of infection. A pressure dressing could obscure signs of bleeding or compromise the catheter’s position.
C. Perform an Allen's test: Allen’s test is performed prior to radial arterial line insertion to assess collateral circulation via the ulnar artery for preventing ischemic complications if the radial artery is compromised. Performing the test afterward does not prevent complications and is no longer relevant once the catheter is placed.
D. Obtain a portable x-ray to confirm placement: X-rays are used to confirm the placement of central lines, not peripheral arterial lines like the radial line. Arterial line placement is confirmed by waveform analysis and blood return, not imaging.
Correct Answer is ["35"]
Explanation
Calculate the total infusion time in minutes.
Infusion time in minutes = 2 hours × 60 minutes/hour
= 120 minutes
Calculate the total number of drops to be infused.
The total volume remaining is 350 mL
Drip factor is 12 gtts/mL.
Total drops = Total volume (mL) × Drop factor (gtts/mL)
Total drops = 350 mL × 12 gtts/mL
= 4200 gtts
Calculate the IV flow rate in drops per minute (gtts/min).
IV rate (gtts/min) = Total drops / Total infusion time (minutes)
= 4200 gtts / 120 minutes
= 35
=35 gtts/min
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