The nurse should monitor the client for clinical manifestations of digoxin toxicity if the laboratory report reflects a serum:
glucose of 110 mg/dL.
potassium of 3.0 mEq/L.
calcium of 9.0 mg/dL.
sodium of 133 mEq/L.
The Correct Answer is B
Choice A reason: Glucose of 110 mg/dL is not a finding that indicates digoxin toxicity. It is a normal blood glucose level for a fasting or non-fasting client.
Choice B reason: Potassium of 3.0 mEq/L is a finding that indicates digoxin toxicity. It is a low serum potassium level, which increases the risk of digoxin toxicity by enhancing the binding of digoxin to cardiac cells. The nurse should monitor the client for signs and symptoms of digoxin toxicity, such as nausea, vomiting, anorexia, fatigue, confusion, visual disturbances, and cardiac arrhythmias.
Choice C reason: Calcium of 9.0 mg/dL is not a finding that indicates digoxin toxicity. It is a normal serum calcium level for an adult client.
Choice D reason: Sodium of 133 mEq/L is not a finding that indicates digoxin toxicity. It is a slightly low serum sodium level, which may indicate hyponatremia, but not digoxin toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
No explanation
Correct Answer is B
Explanation
Choice A reason: Placing a pad under the buttocks is not the best intervention to help prevent skin breakdown. A pad can absorb some of the moisture and protect the bed linen, but it can also trap heat and bacteria and cause irritation and infection of the skin.
Choice B reason: This is the best intervention to help prevent skin breakdown. Checking the rectal area for soiling frequently allows the nurse to remove any fecal matter and clean the skin as soon as possible. This reduces the exposure of the skin to moisture, acidity, and enzymes that can damage the skin integrity and cause inflammation and ulceration.
Choice C reason: Washing the buttocks with strong soap and water is not the best intervention to help prevent skin breakdown. Strong soap can strip the natural oils and protective barrier of the skin and make it more vulnerable to injury and infection. The nurse should use mild soap and water or a pH-balanced cleanser and pat the skin dry gently.
Choice D reason: Placing the call bell in the client's reach is not the best intervention to help prevent skin breakdown. A mentally impaired client may not be able to use the call bell or communicate their needs effectively. The nurse should not rely on the client's ability to ask for help, but rather check on the client regularly and provide appropriate care.
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