A nurse in a clinic is caring for an older adult client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Digoxin Toxicity: The client’s symptoms (nausea, vomiting, diarrhea, weakness), vital signs (bradycardia), and lab results (high digoxin level, low potassium and magnesium) suggest digoxin toxicity.
Cardiac Monitor: To detect any arrhythmias resulting from digoxin toxicity.
Icterus: To assess liver function, which could be impacted in severe toxicity.
Electrolytes: Imbalances in potassium and magnesium can worsen digoxin toxicity and need to be corrected.
Fever: The fever might indicate an infection or inflammatory process, which can affect treatment and recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Condition:
A. Transfusion-associated circulatory overload (TACO)
Rationale: The client’s symptoms—dyspnea, restlessness, crackles in the lungs, jugular vein distension, and elevated blood pressure—are consistent with TACO, a condition resulting from excessive fluid volume during a blood transfusion.
Actions to Take:
C. Administer furosemide
Rationale: Furosemide is a diuretic that helps reduce fluid overload, which is a key issue in TACO.
B. Administer diphenhydramine
Rationale: Although not the primary treatment for TACO, diphenhydramine can help manage symptoms if there is a mild allergic reaction contributing to the situation.
Parameters to Monitor:
A. Intake and output
Rationale: Monitoring intake and output helps assess fluid balance and effectiveness of treatment for TACO.
D. Weight
Rationale: Weight monitoring helps assess fluid overload and effectiveness of diuretic therapy
Correct Answer is B
Explanation
A. Coffee has not been shown to significantly increase the risk of gout attacks and may even have a protective effect due to its antioxidant properties.
B. Alcohol, especially beer and spirits, can trigger gout attacks by increasing the level of uric acid in the blood. Alcohol consumption should be limited or avoided to reduce the risk of gout flare-ups.
C. Milk and other low-fat dairy products are actually recommended for people with gout, as they may help lower uric acid levels.
D. Orange juice, while high in vitamin C, does contain fructose, which can increase uric acid production. However, it is not as significant a trigger as alcohol. Moderation is key.
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