The nurse is assessing a client taking prescribed digoxin (Lanoxin) for heart failure, and the client reports visual disturbances.
Which of the following actions should the nurse take?
Refer the client to see an optometrist.
Ask if the client wears glasses or contact lenses.
Obtain a prescription for stat laboratory tests.
Obtain the client's blood pressure.
The Correct Answer is C
Choice A rationale
Referring the client to see an optometrist is inappropriate because visual disturbances can be a sign of digoxin toxicity, which requires immediate medical attention rather than routine visual examination. Toxicity manifests due to elevated serum digoxin levels, with symptoms including blurred vision and yellow-green halos. Normal digoxin range is 0.5-2.0 ng/mL.
Choice B rationale
Asking if the client wears glasses or contact lenses does not address the root cause of visual disturbances, which is likely linked to digoxin toxicity. Such queries delay prompt medical intervention needed to evaluate and manage the client’s condition. Ocular aids are unrelated to pharmacological adverse effects.
Choice C rationale
Obtaining a prescription for stat laboratory tests is essential for assessing serum digoxin levels and electrolytes, particularly potassium, as hypokalemia increases sensitivity to digoxin toxicity. Prompt identification of toxicity allows timely interventions, including discontinuation of digoxin or administration of antidotes like Digibind.
Choice D rationale
Obtaining the client’s blood pressure is irrelevant in this scenario, as visual disturbances are not indicative of blood pressure abnormalities but rather digoxin toxicity. Immediate focus should be on confirming and managing toxicity through laboratory evaluation and clinical assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hemorrhage is not a typical complication of extracorporeal shock wave lithotripsy (ESWL), as it is a non-invasive procedure targeting kidney stones using shock waves. The risk of significant bleeding is minimal, and monitoring focuses more on urinary changes or localized pain rather than hemorrhage.
Choice B rationale
ESWL does not involve surgical incisions, so there is no incision site to monitor for infection. This action is irrelevant to the procedure's mechanism, which uses external shock waves to fragment stones rather than invasive surgical methods.
Choice C rationale
Sand or gravel in the urine is a common finding after ESWL as the procedure fragments kidney stones into smaller particles. These fragments are excreted through the urinary system. Monitoring urine for these particles helps evaluate the procedure's effectiveness and ensure stones are adequately eliminated.
Choice D rationale
Percutaneous nephrostomy tubes are used for urinary drainage but are not a standard component of ESWL. Monitoring for tube obstruction applies to invasive procedures, whereas ESWL focuses on non-invasive stone fragmentation. This action is unrelated to the client's current treatment modality. .
Correct Answer is D
Explanation
Choice A rationale
Avoiding exposure to cold climates is not specific to thalassemia prevention. While cold environments may exacerbate general vasoconstriction, they do not influence the genetic and hematologic basis of thalassemia symptoms.
Choice B rationale
Increasing fluid intake does not directly address thalassemia pathophysiology. While hydration is vital, it does not correct the primary anemia or the compromised oxygen delivery stemming from abnormal hemoglobin synthesis.
Choice C rationale
Iron and vitamin B12-rich foods are beneficial for conditions involving deficiency anemia. However, thalassemia involves a genetic defect in hemoglobin chains, so excess iron could even result in iron overload complications.
Choice D rationale
Medications and substances that exacerbate hemolysis, such as sulfonamides or antimalarials, should be avoided in thalassemia. Awareness and prevention of exposure are key to minimizing symptoms and complications in affected individuals. .
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