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 B

Explanation

A. "All patients with this disorder have a genetic defect which causes it.": Restrictive cardiomyopathy is not primarily a genetic disorder. While there may be rare familial forms, most cases are acquired, often secondary to systemic diseases, making this statement inaccurate and misleading.

B. "There are many theories about its development but amyloidosis in your history is a probable cause.": This is the most accurate response. Restrictive cardiomyopathy is commonly associated with infiltrative diseases such as amyloidosis, hemochromatosis, and sarcoidosis, which impair ventricular filling due to stiff, non-compliant myocardium.

C. "You probably had a silent heart attack which caused this disorder.": Silent myocardial infarctions can contribute to ischemic cardiomyopathy, typically leading to dilated, not restrictive, changes in the myocardium. They are not a primary cause of restrictive cardiomyopathy.

D. "Your long-standing hypertension caused this disorder.": Chronic hypertension more commonly leads to left ventricular hypertrophy and may contribute to diastolic heart failure, but it is not a typical cause of restrictive cardiomyopathy.

A. BP 105/70 manually & flat neck veins B. Equal breath sounds with a respiratory rate of 28 C. Distended neck veins & muffled heart sounds D. Heart rate 105 & respiratory rate of 28

Correct Answer is C

Explanation

A. BP 105/70 manually & flat neck veins: This blood pressure is within a low-normal range, and flat neck veins suggest no evidence of right-sided heart failure or cardiac tamponade. Though the patient needs evaluation, these findings are not emergent.

B. Equal breath sounds with a respiratory rate of 28: A mildly elevated respiratory rate can indicate distress, but equal breath sounds suggest the absence of pneumothorax or hemothorax. While the patient is symptomatic, this finding alone doesn't demand the most urgent intervention.

C. Distended neck veins & muffled heart sounds: These are classic signs of cardiac tamponade, a life-threatening emergency that can occur due to pacemaker lead perforation. This condition results in fluid accumulation in the pericardial sac, impairing cardiac output and requiring immediate intervention such as pericardiocentesis.

D. Heart rate 105 & respiratory rate of 28: These are signs of physiological compensation and indicate stress or early decompensation. However, without signs like neck vein distention or muffled heart sounds, they are less critical than the findings in option C.

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WBC	8.5
Hemoglobin	17g/dL
Hematocrit	54%
BUN	28mg/dL
Creatinine	1.1 mg/dL
Potassium	4.9 mEq/L

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 B

Explanation

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Correct Answer is C

Explanation

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