The nurse is assessing a client taking prescribed digoxin (Lanoxin) for heart failure, and the client reports visual disturbances.
Which of the following actions should the nurse take?

Refer the client to see an optometrist.

Ask if the client wears glasses or contact lenses.

Obtain a prescription for stat laboratory tests.

Obtain the client's blood pressure.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Referring the client to see an optometrist is inappropriate because visual disturbances can be a sign of digoxin toxicity, which requires immediate medical attention rather than routine visual examination. Toxicity manifests due to elevated serum digoxin levels, with symptoms including blurred vision and yellow-green halos. Normal digoxin range is 0.5-2.0 ng/mL.

Choice B rationale

Asking if the client wears glasses or contact lenses does not address the root cause of visual disturbances, which is likely linked to digoxin toxicity. Such queries delay prompt medical intervention needed to evaluate and manage the client’s condition. Ocular aids are unrelated to pharmacological adverse effects.

Choice C rationale

Obtaining a prescription for stat laboratory tests is essential for assessing serum digoxin levels and electrolytes, particularly potassium, as hypokalemia increases sensitivity to digoxin toxicity. Prompt identification of toxicity allows timely interventions, including discontinuation of digoxin or administration of antidotes like Digibind.

Choice D rationale

Obtaining the client’s blood pressure is irrelevant in this scenario, as visual disturbances are not indicative of blood pressure abnormalities but rather digoxin toxicity. Immediate focus should be on confirming and managing toxicity through laboratory evaluation and clinical assessment.

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 B

Explanation

Choice A rationale

Magnesium and bilateral lower extremity ultrasounds are not primary diagnostic tests for hypertension-related target organ damage. Magnesium levels do not directly correlate with hypertension complications, and lower extremity ultrasounds mainly evaluate vascular issues, such as deep vein thrombosis, rather than organs affected by chronic hypertension.

Choice B rationale

Urinalysis assesses kidney function by detecting proteinuria, an indicator of renal damage due to hypertension. Blood chemistry provides electrolytes and renal function metrics, like creatinine (normal range: 0.6–1.2 mg/dL). A 12-lead ECG identifies left ventricular hypertrophy or arrhythmias linked to cardiac strain from persistent high blood pressure, a common sign of target organ damage.

Choice C rationale

Complete blood count evaluates overall health but does not specifically target organ damage related to hypertension. Electroencephalogram measures brain activity and is more relevant for neurological conditions, such as seizures, not complications from high blood pressure.

Choice D rationale

Troponin evaluates myocardial injury in acute settings like myocardial infarction, unrelated to chronic hypertension-induced organ damage. Calcium levels and partial thromboplastin time assess coagulation and bone health but do not directly indicate target organ involvement in hypertension.

A. Notify a urologist to insert a metal catheter with a prostatic curve. B. Prepare the client to have a cystostomy performed. C. Insert an indwelling urethral catheter. D. Notify the health care provider to discuss surgical options with the client.

Correct Answer is C

Explanation

Choice A rationale

Metal catheters with prostatic curves are used in challenging cases of urinary retention caused by BPH. However, these catheters are not the first-line intervention due to their specialized nature and the risk of injury. Less invasive measures should be tried first.

Choice B rationale

Cystostomy, a surgical procedure that creates a suprapubic urinary drainage site, is reserved for severe cases of urinary retention where catheterization fails. It is not the initial step due to its invasive nature and requirement for surgical expertise.

Choice C rationale

Inserting an indwelling urethral catheter is the first-line action for managing acute urinary retention associated with BPH. It provides immediate bladder decompression, relieves discomfort, and reduces risks of complications like hydronephrosis or bladder rupture.

Choice D rationale

Discussing surgical options addresses the long-term management of BPH but does not resolve acute urinary retention. Interventions like catheterization should first alleviate symptoms before evaluating the need for definitive surgical treatment. .

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

The nurse is assessing a client taking prescribed digoxin (Lanoxin) for heart failure, and the client reports visual disturbances.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with hypertension who is being assessed for possible target organ damage.The nurse should monitor the results of which of the following diagnostic tests?

Correct Answer is B

Explanation

The nurse is caring for a male client with a history of benign prostatic hyperplasia (BPH) who reports being unable to void any urine for the last 8 hours.Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

The nurse is explaining to a client diagnosed with heart failure that the client's heart muscle has thickened on the right side and is not able to fill properly.The nurse is explaining which of the following types of heart failure?

The nurse is assessing a client taking prescribed digoxin (Lanoxin) for heart failure, and the client reports visual disturbances.Which of the following actions should the nurse take?

The nurse is explaining to a client diagnosed with heart failure that the client's heart muscle has thickened on the right side and is not able to fill properly. The nurse is explaining which of the following types of heart failure?

The nurse has taught nutrition management for a client diagnosed with oxalate kidney stones.Which of the following food choices by the client would indicate that the client requires more teaching?

The nurse is evaluating a client at a one-month check-up who is being treated for hypertension through lifestyle modifications.Which of the following findings would be a priority for the nurse to follow up?

The nurse is assessing a client suspected of having peripheral artery disease (PAD) in the legs.Which of the following findings should the nurse expect during the assessment?

The nurse is assessing a client taking prescribed digoxin (Lanoxin) for heart failure, and the client reports visual disturbances.
Which of the following actions should the nurse take?