Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a 65-year-old male client in a cardiac clinic. The client was recently discharged from an acute hospital stay for worsening heart failure. Below are the exhibits related to the client’s condition:

Exhibit 1: Nurses’ Notes 2 Weeks Ago

The client was admitted to the hospital two weeks ago with worsening heart failure. He was experiencing significant shortness of breath, fatigue, and 2+ edema on bilateral lower extremities. Upon auscultation, an S3 heart sound was noted, and occasional expiratory wheezing was present. The client was managed with furosemide, captopril, and metoprolol at home, but these medications were not sufficient to control his symptoms.

Exhibit 2: Nurses’ Notes Today

The client reports some improvement in shortness of breath with exertion but continues to feel fatigued. Upon auscultation, an S3 heart sound is still noted, and lung sounds are clear. The client has 1+ edema on the ankles and reports nausea, constipation, and blurred vision.

Exhibit 3: History and Physical

The client was discharged from the hospital two days ago after being treated for worsening heart failure. During the hospitalization, he was prescribed digoxin and a potassium supplement in addition to his existing medications. The client will return to the office in two weeks to review lab work and medication management.

Exhibit 4: Laboratory Results Today

Digoxin: 2.2 ng/mL (0.8 to 2 ng/mL)

Potassium: 4.8 mEq/L (3.5 to 5 mEq/L)

Exhibit 5: Vital Signs Today

Temperature: 36.8°C (98.2°F)

Heart rate: 55/min

Respiratory rate: 16/min

Blood pressure: 110/80 mm Hg

Oxygen saturation: 96% on room air

Click to highlight the findings that indicate the client may be experiencing digoxin toxicity. To deselect a finding, click on the finding again.

Digoxin: 2.2 ng/mL (0.8 to 2 ng/mL)

Heart rate: 55/min

nausea

constipation

blurred vision

being treated for worsening heart failure

an S3 heart sound was noted, and occasional expiratory wheezing was present

Answer and Explanation

The Correct Answer is ["A","B","C","E"]

The findings that indicate the client may be experiencing digoxin toxicity are:

Digoxin level: 2.2 ng/mL (above the therapeutic range of 0.8 to 2 ng/mL)
Heart rate: 55/min (bradycardia, which can be a sign of digoxin toxicity)
Nausea
Blurred vision

These symptoms and lab results are consistent with digoxin toxicity.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","F"]

Explanation

Choice A rationale
Thrombocytopenia, a low platelet count, increases the risk of bleeding and hemorrhage when receiving heparin.
Choice B rationale
Neutropenia, a low white blood cell count, does not directly increase the risk of hemorrhage. It is more related to infection risk.
Choice C rationale
Hypokalemia, low potassium levels, does not directly indicate a risk for hemorrhage. It can cause other complications but not specifically bleeding.
Choice D rationale
Fever is not a direct indicator of hemorrhage risk. It may indicate infection or other inflammatory processes.
Choice E rationale
Hyperglycemia, high blood sugar levels, does not indicate a risk for hemorrhage. It is more related to diabetes management.
Choice F rationale
Dark stools can indicate gastrointestinal bleeding, which is a sign of hemorrhage.

A. Ask the client to describe their concerns. B. Contact the provider who prescribed the immunization. C. Provide the client with education about the immunization. D. Document the client’s refusal of the immunization.

Correct Answer is A

Explanation

Choice A rationale
Asking the client to describe their concerns allows the nurse to understand the client’s perspective and address any misconceptions or fears they may have about the influenza immunization.
Choice B rationale
Contacting the provider is important but should be done after understanding the client’s concerns to provide a comprehensive report.
Choice C rationale
Providing education is essential but should follow understanding the client’s specific concerns to tailor the information effectively.
Choice D rationale
Documenting the refusal is necessary but should be done after addressing the client’s concerns and providing education.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving an IV infusion of heparin. Which of the following findings should indicate to the nurse the client is at risk for hemorrhage? (Select all that apply.)

Correct Answer is ["A","F"]

Explanation

A nurse is caring for a client who refuses a prescribed influenza immunization. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who has a new prescription for folic acid. The client states, “I thought that was only given during pregnancy.”. Which of the following statements should the nurse make?

A nurse is caring for a client receiving an intermittent IV bolus of gentamicin twice daily. Which of the following laboratory values should the nurse monitor while the client is receiving this medication? (Select all that apply.)

A nurse is teaching a client who has a seizure disorder about their medication. Which of the following client statements indicates an understanding of the teaching?

A nurse is caring for a client following a bronchoscopy with moderate sedation. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a 40-year-old male client in the postanesthesia care unit (PACU) following abdominal surgery. Exhibits Complete the following sentence by using the list of options provided. The nurse should first address the client’s:_________ followed by __________

A nurse is providing teaching to a client who has a new prescription for allopurinol to treat gout. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has osteoporosis and a new prescription for alendronate. Which of the following should the nurse assess prior to initiating therapy?

A nurse is providing teaching to a client who has angina and a new prescription for nitroglycerin tablets. Which of the following instructions should the nurse include in the teaching?