The nurse is assessing a patient with myocarditis before giving a scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider?.
Irregular pulse.
Leukocytosis.
Generalized myalgia.
Fatigue.
The Correct Answer is A
Choice A rationale:
An irregular pulse could indicate that myocarditis is affecting the heart’s electrical system, leading to an irregular heartbeat or arrhythmia. This could potentially affect the action of digoxin, a medication used to treat heart conditions, and therefore should be communicated to the healthcare provider.
Choice B rationale:
Leukocytosis, or a high white blood cell count, can be a sign of infection or inflammation, including myocarditis. However, it is not as specific as an irregular pulse in indicating a potential issue with the administration of digoxin.
Choice C rationale:
Generalized myalgia, or muscle pain, can be a symptom of myocarditis. However, it is not as directly related to the action of digoxin as an irregular pulse.
Choice D rationale:
Fatigue can be a symptom of myocarditis. However, it is not as directly related to the action of digoxin as an irregular pulse.
So, the correct answer is A, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A rationale:
Dependent rubor refers to redness of the skin that occurs when the leg is in a dependent (hanging down) position. It is often associated with peripheral artery disease. However, the child’s symptoms do not indicate this condition.
Choice B rationale:
Digitalis toxicity can occur as a result of high levels of the drug digoxin. Symptoms can include nausea, vomiting, weakness, and vision changes. Given that the child has been administered digoxin, there is a risk for this condition.
Choice C rationale:
Carditis is inflammation of the heart or its surroundings. It is usually caused by bacterial or viral infections. The child’s symptoms do not suggest an infection, making this choice less likely.
Choice D rationale:
Hypercyanotic spells, also known as “tet spells,” are associated with Tetralogy of Fallot, a specific congenital heart defect. The child has a history of congenital mitral stenosis, not Tetralogy of Fallot, making this choice less likely.
Choice E rationale:
Hypokalemia, or low potassium levels, can occur as a side effect of taking diuretics like furosemide. Given that the child has been administered furosemide, there is a risk for this condition.
Choice F rationale:
Fever is usually a response to infection or inflammation. The child’s symptoms do not suggest an infection or inflammation, making this choice less likely.
Choice G rationale:
Hypertension, or high blood pressure, is not indicated in the child’s symptoms or history. The child’s blood pressure readings are within normal range, making this choice less likely.
Choice H rationale:
A murmur is a sound that can be heard when listening to the heart with a stethoscope. It is often caused by turbulent blood flow through the heart. The child’s notes do not mention a murmur, making this choice less likely.
So, the correct answer is, the child is at risk for developing Digitalis toxicity and Hypokalemia. .
Correct Answer is ["B","C","D","F"]
Explanation
Choice A rationale:
The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.
Choice B rationale:
The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.
Choice C rationale:
The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.
Choice D rationale:
The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.
Choice E rationale:
The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function
Choice F rationale:
On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.
So, the correct answer is Choices B, C, D, and F, after analyzing all choices.
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