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

Begin cardioversion to stabilize heart rhythm.

Give digoxin by another route to slow absorption.

Administer potassium to stabilize the heart rate.

Check acid-base and electrolyte values.

Answer and Explanation

The Correct Answer is D

Begin cardioversion to stabilize heart rhythm: Cardioversion is not the appropriate intervention for digoxin toxicity. Digoxin toxicity can cause arrhythmias, but the initial action should be to assess and manage the underlying cause, rather than immediately proceeding to cardioversion.

B) Give digoxin by another route to slow absorption: Slowing the absorption of digoxin is not the appropriate action for treating digoxin toxicity. Instead, the focus should be on managing the existing toxicity and preventing further absorption by withholding additional doses.

C) Administer potassium to stabilize the heart rate: While potassium may be indicated as part of the treatment for digoxin toxicity, particularly if hypokalemia is contributing to the toxicity, it is not the initial action. The priority is to assess the client’s acid-base and electrolyte values to identify any abnormalities contributing to the toxicity.

D) Check acid-base and electrolyte values: This is the correct action. Digoxin toxicity can be exacerbated by electrolyte imbalances, particularly hypokalemia, hypercalcemia, and hypomagnesemia. Therefore, assessing the client’s acid-base and electrolyte values is essential to identify and correct any abnormalities contributing to the toxicity. Once identified, appropriate interventions can be implemented to manage the toxicity and stabilize the client’s condition.

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Correct Answer is D

Explanation

A) Take the benzodiazepine at the same time of taking the morphine: This statement is incorrect. Benzodiazepines and morphine are both central nervous system depressants and can potentiate each other’s effects, leading to increased sedation and respiratory depression. Taking them together without proper supervision or dosage adjustment can be dangerous. Therefore, this statement indicates a misunderstanding of the medication regimen.

B) Do not drink grapefruit juice after taking morphine: While grapefruit juice can interact with certain medications by affecting their metabolism, there is no specific interaction between grapefruit juice and morphine that requires avoidance. Therefore, this statement is not directly related to the use of morphine for bone pain.

C) Watch for signs of agitation and record any insomnia: While it is important to monitor for side effects of morphine, such as agitation and insomnia, this statement does not directly relate to the management of constipation, which is a common side effect of opioid analgesics like morphine.

D) Observe bowel movement pattern and take a stool softener: This is the correct answer. Morphine is known to cause constipation as a side effect due to its action on opioid receptors in the gastrointestinal tract. Therefore, monitoring bowel movements and taking a stool softener can help prevent or alleviate constipation associated with morphine use. This statement indicates an understanding of the potential side effects of the medication and the importance of managing them appropriately.

A. Be aware that difficulty sleeping and weight loss may occur. B. Administer each dose with at least 8 ounces (240 ml) of water. C. Consume tyramine-free foods while taking the medicine. D. Notify the healthcare provider if experiencing changes in taste.

Correct Answer is A

Explanation

A) Be aware that difficulty sleeping and weight loss may occur: This is the correct answer. Bupropion is associated with potential side effects such as insomnia and weight loss. It is essential for the nurse to inform the client about these possible adverse effects to ensure they are aware and can monitor for them. By being informed, the client can report any concerns promptly to their healthcare provider.

B) Administer each dose with at least 8 ounces (240 ml) of water: While it is generally advisable to take medications with a full glass of water, this instruction is not specifically related to bupropion. Therefore, it is not the most pertinent information for discharge teaching regarding this medication.

C) Consume tyramine-free foods while taking the medicine: This instruction is not relevant to bupropion. Tyramine restriction is typically associated with monoamine oxidase inhibitors (MAOIs), not bupropion.

D) Notify the healthcare provider if experiencing changes in taste: Changes in taste are not commonly associated with bupropion use. While it is important to monitor for and report any unusual symptoms while taking medication, difficulty sleeping and weight loss are more commonly observed adverse effects of bupropion that should be emphasized in discharge teaching for a client prescribed this medication to reduce nicotine cravings.

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

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