A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take?

Measure the client's apical pulse rate for 30 seconds before administration.

Withhold the medication if the client's heart rate is above 100/min.

Instruct the client to eat foods that are low in potassium.

Monitor the client for nausea, vomiting, and yellow vision.

Answer and Explanation

The Correct Answer is D

A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.

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Correct Answer is D

Explanation

A. While hyperlipidemia can contribute to vascular damage, it primarily increases the risk of cardiovascular disease and stroke, rather than directly blocking neuron communication to cause dementia.
B. Peptic ulcer disease is not associated with dementia, and the loss of nerve cells in the stomach does not lead to cognitive decline.
C. Peptic ulcer disease does not cause dementia by impacting neuron communication in the stomach.
D. Vascular dementia is often caused by stroke due to reduced blood flow or damage to the blood vessels in the brain, leading to cognitive decline and memory loss.

A. Nicardipine B. Phenytoin C. Dopamine D. Mannitol

Correct Answer is D

Explanation

A. Nicardipine is a calcium channel blocker primarily used to manage blood pressure but does not directly reduce ICP.
B. Phenytoin is an anticonvulsant used to prevent seizures, which may occur after a hemorrhage, but it does not address increased ICP.
C. Dopamine is used to increase blood pressure and cardiac output but does not play a role in reducing ICP.
D. Mannitol is an osmotic diuretic that helps decrease ICP by drawing fluid from brain tissue into the bloodstream, thus relieving pressure within the skull. It is the most appropriate intervention for managing increased ICP.

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A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is D

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