The nurse assesses a client who is prescribed digoxin. The client reports nausea and seeing green halos. Which action should the nurse perform?

Administer the dose later in the day when their nausea subsides

Assess the client's apical rate

Contact the physician for STAT serum potassium level

Administer the client's prescribed dose intravenously

Answer and Explanation

The Correct Answer is B

A. Administer the dose later in the day when their nausea subsides: Delaying the dose does not address the underlying concern of potential digoxin toxicity. Symptoms like nausea and visual disturbances suggest toxicity and require immediate assessment rather than postponement.

B. Assess the client's apical rate: The first and most appropriate nursing action is to assess the apical heart rate for one full minute, as bradycardia is a key indicator of digoxin toxicity. If the rate is below 60 bpm, the dose should be held, and the provider should be notified.

C. Contact the physician for STAT serum potassium level: Hypokalemia increases the risk of digoxin toxicity, but while checking potassium is important, it is not the first step. Assessment of heart rate is more immediately critical in evaluating the need to hold the medication.

D. Administer the client's prescribed dose intravenously: Administering the dose especially IV when the client has symptoms of toxicity could worsen the situation. Digoxin should be held, not given, until further evaluation and provider notification.

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Correct Answer is A

Explanation

A. the heart rate is greater than 100 bpm in sinus tachycardia: Normal Sinus Rhythm is characterized by a heart rate between 60 and 100 beats per minute (bpm). Sinus tachycardia is defined as a sinus rhythm with a heart rate exceeding 100 beats per minute. The rhythm remains regular, with each P wave followed by a QRS complex, but the rate is significantly faster than normal sinus rhythm.

B. more p waves are present than QRS complexes: In sinus tachycardia, the number of P waves and QRS complexes remains one-to-one, as each atrial impulse continues to be conducted to the ventricles. More P waves than QRS complexes typically suggest atrial flutter or other forms of AV dissociation.

C. the QRS complexes measure greater than 0.10: A widened QRS complex suggests a bundle branch block or ventricular rhythm, not sinus tachycardia. In sinus tachycardia, QRS complexes typically remain narrow, measuring less than 0.10 seconds unless an intraventricular conduction delay is present.

D. the rhythm is often irregular in sinus tachycardia: Sinus tachycardia is usually a regular rhythm with consistent R-R intervals. An irregular rhythm is more indicative of atrial fibrillation or sinus arrhythmia, not a defining characteristic of sinus tachycardia.

A. Increase in systolic blood pressure 10 mmHg above client's norm B. reports dyspnea after walking up 2 flights of stairs C. Jugular vein distention and +3 peripheral edema D. Complaints of epigastric pain after eating a large meal

Correct Answer is C

Explanation

A. Increase in systolic blood pressure 10 mmHg above client's norm: A mild increase in systolic blood pressure is not a specific indicator of mitral stenosis progression. Blood pressure fluctuations may occur due to various factors and are not typically used as a primary marker of worsening valve disease.

B. reports dyspnea after walking up 2 flights of stairs: Exertional dyspnea is a common early symptom of mitral stenosis due to reduced left atrial emptying and pulmonary congestion. However, this does not necessarily indicate worsening unless the symptom becomes more severe or occurs with minimal exertion.

C. Jugular vein distention and +3 peripheral edema: These are signs of right-sided heart failure, which may result from long-standing mitral stenosis leading to pulmonary hypertension and subsequent right ventricular hypertrophy and failure. This indicates disease progression and worsening cardiac function.

D. Complaints of epigastric pain after eating a large meal: Epigastric discomfort is not a typical symptom of mitral stenosis and is more likely related to gastrointestinal issues. It does not reflect the status or progression of the cardiac condition.

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The nurse assesses a client who is prescribed digoxin. The client reports nausea and seeing green halos. Which action should the nurse perform?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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