A client is being treated for heart failure. Labs: Sodium 146, Potassium 2.9, Hemoglobin 10.5, White Blood Cells 12.2 VS: BP 118/66, apical heart rate 68, O2 96% on 2L nasal cannula, temperature 98.4F
What will the nurse do with the digoxin order?
Recheck heart rate in one hour.
Hold the digoxin and call the MD.
Call prescriber and ask for chest x-ray.
Give the digoxin as ordered.
The Correct Answer is B
Choice A reason: This statement is false. The nurse should not delay the administration of digoxin based on the heart rate alone, unless it is below 60 beats per minute. The nurse should also consider the serum potassium level, which is low in this case and increases the risk of digoxin toxicity.
Choice B reason: This statement is true. The nurse should hold the digoxin and call the MD, as the client has a low potassium level, which can potentiate the effects of digoxin and cause arrhythmias, nausea, vomiting, or visual disturbances. The MD may order a serum digoxin level, potassium supplementation, or a dose adjustment.
Choice C reason: This statement is false. The nurse does not need to call the prescriber and ask for a chest x-ray, as this is not relevant to the digoxin order. A chest x-ray may be indicated to assess the severity of heart failure, but it does not affect the decision to administer digoxin.
Choice D reason: This statement is false. The nurse should not give the digoxin as ordered, as the client has a low potassium level, which can increase the risk of digoxin toxicity. The nurse should hold the digoxin and call the MD for further instructions..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is false. The nurse would not be alerted by a heart rate of 95, as this is within the normal range of 60 to 100 beats per minute. Desmopressin is a synthetic form of antidiuretic hormone (ADH) that reduces urine output and increases water retention in the body. It does not affect the heart rate significantly.
Choice B reason: This statement is false. The nurse would not be alerted by an oxygen saturation of 93%, as this is within the normal range of 95% to 100%. Desmopressin is a synthetic form of antidiuretic hormone (ADH) that reduces urine output and increases water retention in the body. It does not affect the oxygen level in the blood.
Choice C reason: This statement is false. The nurse would not be alerted by a hemoglobin of 14.1, as this is within the normal range of 12 to 18 grams per deciliter. Desmopressin is a synthetic form of antidiuretic hormone (ADH) that reduces urine output and increases water retention in the body. It does not affect the hemoglobin level in the blood.
Choice D reason: This statement is true. The nurse would be alerted by a blood pressure of 170/90, as this is above the normal range of 120/80 or lower. Desmopressin is a synthetic form of antidiuretic hormone (ADH) that reduces urine output and increases water retention in the body. However, it can also cause hypertension, which is a condition where the blood pressure is too high. Hypertension can damage the blood vessels and organs, such as the heart, kidneys, and brain. The nurse should monitor the client's blood pressure closely and report any changes to the prescriber.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: This statement is true. The nurse should include tremors as a sign of hypoglycemia, which is a condition where the blood glucose level is too low. Tremors are involuntary shaking or trembling of the body, caused by the release of adrenaline in response to low blood glucose.
Choice B reason: This statement is true. The nurse should include diaphoresis as a sign of hypoglycemia, which is excessive sweating, caused by the activation of the sympathetic nervous system in response to low blood glucose.
Choice C reason: This statement is true. The nurse should include confusion as a sign of hypoglycemia, which is impaired mental function, caused by the lack of glucose supply to the brain.
Choice D reason: This statement is false. The nurse should not include polyuria as a sign of hypoglycemia, which is increased urination, caused by the excess glucose in the urine. Polyuria is more common with hyperglycemia, which is a condition where the blood glucose level is too high.
Choice E reason: This statement is false. The nurse should not include polydipsia as a sign of hypoglycemia, which is increased thirst, caused by the dehydration from polyuria. Polydipsia is also more common with hyperglycemia, which is a condition where the blood glucose level is too high.
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