The nurse prepares to administer digoxin 0.125 mg PO to a client who has chronic heart failure. The laboratory report reveals a digoxin level of 2.5 mg/mL. Which nursing action is most appropriate at this time?

Assess the apical pulse and if above 60 beats/minute administer the dose.

Administer 0.25 mcg and potassium 20 mEq IV.

Withhold the medication and notify the healthcare provider of the digoxin level.

Administer the digoxin with a potassium supplement.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is incorrect. Assessing the apical pulse is not enough to determine if the client is safe to receive digoxin. The client's digoxin level is already above the therapeutic range of 0.5 to 2 ng/mL¹² and giving another dose could increase the risk of toxicity and arrhythmias.

Choice B reason: This is incorrect. Administering 0.25 mcg of digoxin and potassium 20 mEq IV is not appropriate for this client. The client does not need more digoxin or potassium, as both could worsen the client's condition. Potassium levels should be monitored closely in clients taking digoxin, as low or high levels can affect the drug's action and toxicity³.

Choice C reason: This is correct. Withholding the medication and notifying the healthcare provider of the digoxin level is the most appropriate action for this client. The client's digoxin level is dangerously high and could cause serious adverse effects such as nausea, vomiting, vision changes, bradycardia, and cardiac arrest³. The healthcare provider may order to stop digoxin temporarily, adjust the dose, or prescribe an antidote such as digoxin immune fab⁴.

Choice D reason: This is incorrect. Administering the digoxin with a potassium supplement is not advisable for this client. The client's digoxin level is already too high and adding potassium could increase the risk of hyperkalemia, which can impair the heart's electrical activity and lead to cardiac arrest³. Potassium supplements should only be given to clients with digoxin-induced hypokalemia, and only under the supervision of the healthcare provider³..

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Correct Answer is C

Explanation

Choice A reason: Limiting the intake of citrus juices is not related to the teaching about hydrochlorothiazide. Citrus juices are rich in vitamin C, which has no significant interaction with hydrochlorothiazide. The client does not need to avoid or limit citrus juices unless they have other medical conditions that require dietary restrictions.

Choice B reason: Eating bananas daily to lower the potassium level is a wrong statement. Bananas are high in potassium, which is a mineral that hydrochlorothiazide can deplete from the body. The client may need to increase their potassium intake or take a potassium supplement to prevent hypokalemia, a condition of low potassium level that can cause muscle weakness, cramps, and arrhythmias.

Choice C reason: Taking the pill each day in the morning is the correct statement. Hydrochlorothiazide is a diuretic that increases the urine output and reduces the blood volume and pressure. The client should take the pill in the morning to avoid nocturia, which is frequent urination at night that can disrupt the sleep quality and increase the risk of falls.

Choice D reason: Taking the pill each day after dinner is not the best statement. Hydrochlorothiazide can cause diuresis, which is increased urine production and excretion. Taking the pill after dinner can lead to nocturia, which is frequent urination at night that can interfere with the sleep cycle and cause fatigue and irritability. The client should take the pill in the morning to prevent nocturia and its complications.

A. Prepare for endotracheal intubation and ventilatory support. B. Provide continuous sedation for pain relief. C. Initiate cardiac monitoring and assess for reflex bradycardia. D. Maintain IV fluid infusion and assess adequacy of hydration.

Correct Answer is D

Explanation

hoice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.

Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.

Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.

Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.

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The nurse prepares to administer digoxin 0.125 mg PO to a client who has chronic heart failure. The laboratory report reveals a digoxin level of 2.5 mg/mL. Which nursing action is most appropriate at this time?

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a client with hypertension about the prescribed hydrochlorothiazide 10 mg PO daily. Which statement, made by the client, would indicate that the teaching has been effective? "I will:

Correct Answer is C

Explanation

A client is experiencing a thyroid storm precipitated by a right lower lobe pneumonia. The vital signs are: HR-140/min; RR-28, B/P-196/54; T-101.4°F, Pulse Oximetry-96%. What action should the nurse take?

Correct Answer is D

Explanation

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