The nurse should monitor the client for signs and symptoms of digoxin toxicity if the laboratory report reflects a serum:

sodium of 133 mg/dl.

glucose of 110 mg/dl.

potassium of 3.0 mEq/L.

calcium of 9.0 mg/dl.

Answer and Explanation

The Correct Answer is C

C. Digoxin toxicity is a serious condition that can occur when there is too much digoxin in the body. It can lead to life-threatening cardiac dysrhythmias. One of the risk factors for digoxin toxicity is low blood levels of potassium, or hypokalemia.
A. Electrolyte imbalances, including hyponatremia (low sodium levels), can contribute to digoxin toxicity. However, a sodium level of 133 mg/dl alone does not directly indicate digoxin toxicity.
B. Blood glucose levels within the normal range (80-120 mg/dl) would not directly indicate digoxin toxicity.
D. Calcium levels within the normal range (8.5-10.5 mg/dl) do not directly indicate digoxin toxicity.

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Correct Answer is A

Explanation

A. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.

A. discourage the client from discussing feelings of fear and inferiority. B. provide positive reinforcement for acting-out behavior. C. be consistent in staff limit setting. D. ignore, rather than confront, inappropriate behavior.

Correct Answer is C

Explanation

C. This approach involves establishing clear and consistent rules and boundaries, which are crucial for managing antisocial behaviors. It helps to create a structured environment where the consequences of actions are predictable and reinforces the understanding of acceptable behaviors.
A. Encouraging the client to explore and address underlying emotions, including feelings of fear and inferiority, can be an important aspect of therapy and may help mitigate manipulative behaviors over time.
B. Antisocial personality disorder is associated with behaviors that violate social norms and the rights of others. Positive reinforcement for these behaviors would not address the underlying issues and may inadvertently reinforce harmful patterns of behavior.
D. Ignoring inappropriate behavior may reinforce the notion that manipulation is an effective means of achieving desired outcomes and may lead to further boundary violations.

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The nurse should monitor the client for signs and symptoms of digoxin toxicity if the laboratory report reflects a serum:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:

Correct Answer is A

Explanation

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

Correct Answer is C

Explanation

The nurse is administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

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