A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my provider if I experience muscle weakness."

"I will take this medication with fiber to prevent constipation."

"I will increase my dose if my vision becomes blurred."

"I will take my digoxin if my pulse is less than 50 beats per minute."

Answer and Explanation

The Correct Answer is A

A. Muscle weakness can be a sign of digoxin toxicity, especially if it is accompanied by other symptoms like nausea, vomiting, or blurred vision. The client should notify the provider immediately if these symptoms occur.

B. Taking digoxin with fiber is not necessary and may interfere with its absorption. The client should take digoxin on an empty stomach, or as directed by the provider, but not specifically with fiber to prevent constipation.

C. Increasing the dose of digoxin if the client experiences blurred vision could be dangerous. Blurred vision is actually a symptom of digoxin toxicity, and the client should not increase the dose but should notify the provider immediately.

D. The nurse should advise the client to hold the digoxin if their pulse is less than 60 beats per minute (not 50), as this could indicate bradycardia caused by digoxin. The client should contact their provider before taking the medication if their pulse is too low.

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Correct Answer is A

Explanation

A. Decreased blood pressure is a key indicator of dehydration. When a client is dehydrated, there is a reduction in circulating blood volume, which can lead to hypotension. This is a common sign of dehydration, especially in cases of gastroenteritis where fluid loss occurs through vomiting and diarrhea.

B. Pitting, dependent edema is more commonly associated with fluid retention or conditions like heart failure or kidney disease, not dehydration. Dehydration typically results in fluid volume deficit, not excess fluid retention.

C. Distended jugular veins are usually indicative of fluid overload, not dehydration. This is often seen in conditions like heart failure, where the body cannot effectively manage fluid volume.

D. Increased blood pressure is not typically a sign of dehydration. Dehydration tends to lead to decreased blood pressure due to reduced blood volume.

A. Encourage the client to urinate every 2 hr. B. Secure the urinary catheter to the upper left quadrant of the client's abdomen. C. Use 0.9% sodium chloride to perform an intermittent bladder irrigation. D. Apply a cold compress to the suprapubic area.

Correct Answer is C

Explanation

A. Encouraging the client to urinate every 2 hr is not appropriate in this situation because the client is receiving continuous bladder irrigation (CBI), and the urinary catheter is meant to drain continuously. The issue is likely related to a blockage or clot in the catheter, not the need for the client to urinate.

B. Securing the urinary catheter to the upper left quadrant is not appropriate because the catheter should be positioned properly to allow for proper drainage. Securing it in an inappropriate location could cause kinks or obstructions.

C. Using 0.9% sodium chloride to perform an intermittent bladder irrigation is the correct action. The client’s scant amount of fluid and bladder spasms suggest that the catheter may be blocked, likely by a clot. Performing an intermittent irrigation with saline can help clear any obstructions in the catheter and restore proper drainage.

D. Applying a cold compress to the suprapubic area is not appropriate for treating bladder spasms caused by a potential obstruction. The priority action is to clear the catheter and ensure proper drainage.

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A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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