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A nurse is collecting data from a client prior to the administration of digoxin. Which of the following findings should the nurse report to the provider?

Potassium level of 3.0 mEq/L

Heart rate of 66/min

BP of 132/82 mm Hg

Digoxin level of 1.2 ng/ml

Answer and Explanation

The Correct Answer is A

a. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a

potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.

b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to

treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.

c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.

d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.

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Correct Answer is C

Explanation

a. Battle's sign: Battle's sign is bruising over the mastoid process and is not a direct manifestation of increased intracranial pressure.

b. Nuchal rigidity: Nuchal rigidity (stiff neck) is associated with irritation of the meninges and is not a specific sign of increased intracranial pressure.

c. Lethargy: Lethargy or altered level of consciousness is a common manifestation of increased intracranial pressure. It can range from mild drowsiness to severe impairment of consciousness.

d. Polyuria: Polyuria is not a typical manifestation of increased intracranial pressure. Increased urine output may be associated with other conditions, such as diabetes or diuretic use.

A. Emesis of 100 mL B. Oral temperature of 37.5" C (99.5° F) C. Pain level of 4 on a 0 to 10 rating scale D. Thick, red-colored urine

Correct Answer is D

Explanation

a. Emesis of 100 mL: While emesis is a concern, the priority is to address potential complications related to the surgical procedure first.

b. Oral temperature of 37.5" C (99.5° F): This temperature is within a normal range, and it is not an immediate concern.

c. Pain level of 4 on a 0 to 10 rating scale: Pain is important to address, but the priority is to assess for potential complications such as bleeding or infection.

d. Thick, red-colored urine: This finding suggests the possibility of bleeding, which could be a complication of the TURP procedure. It is the priority finding to report to the provider for further evaluation.

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