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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Breastfeeding is not recommended while taking this medication: While it’s important for clients to avoid breastfeeding while taking isotretinoin due to potential harm to the infant, the primary concern for a young adult female planning to become pregnant is the risk of teratogenic effects on the fetus. Therefore, while this information is relevant, it’s not the most important consideration in this situation.
B) Do not take multiple vitamins that contain vitamin A while taking this drug: Avoiding excessive intake of vitamin A is essential to prevent toxicity, but it’s not the most critical consideration for a client planning to become pregnant. The main concern is the teratogenic effects of isotretinoin on the fetus.
C) Baseline liver function results must be obtained during therapy: Monitoring liver function is important during isotretinoin therapy to assess for potential hepatotoxicity, but it’s not the most crucial consideration for a client planning to become pregnant. The primary concern is the need to discontinue the medication before conception to prevent fetal exposure.
D) Discontinue this medication one month before attempting to conceive: This is the most important information for the nurse to provide to the client. Isotretinoin is highly teratogenic and can cause severe birth defects if taken during pregnancy. Therefore, it’s essential for the client to discontinue isotretinoin at least one month before attempting to conceive to ensure the drug is cleared from the body and to prevent fetal exposure.
Correct Answer is C
Explanation
A) Tamsulosin is typically administered once daily, not on a twice-weekly dosing schedule. Instructing the client to adhere to the prescribed dosing frequency is essential for maintaining therapeutic blood levels of the medication and optimizing its effectiveness in managing urinary retention associated with benign prostatic hyperplasia (BPH).
B) While the timing of medication administration can impact its effectiveness, taking tamsulosin early in the day versus later in the day may not significantly affect its therapeutic action. The key consideration with tamsulosin is to maintain consistency in timing to ensure a steady plasma concentration of the drug.
C) Instructing the client to stand and sit up slowly is crucial because tamsulosin, as an alpha-blocker, can cause orthostatic hypotension, especially when first starting the medication or when increasing the dosage. By advising the client to change positions slowly, the nurse helps prevent falls and dizziness, which are common side effects associated with sudden drops in blood pressure.
D) Reducing daily fluid intake is not advisable, especially for a client with urinary retention. Maintaining adequate hydration is essential for overall health and urinary function. Tamsulosin works by relaxing the smooth muscles of the prostate and bladder neck, facilitating urine flow, but it does not directly affect fluid intake requirements.
Therefore, the most important instruction for the nurse to provide is to stand and sit up slowly to minimize the risk of orthostatic hypotension and associated complications.
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