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.

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Correct Answer is D

Explanation

Choice A rationale

A low-sodium, high-calorie diet is not the priority for immediate management of renal colic. Nutritional changes are addressed as part of long-term care but do not alleviate acute pain and discomfort caused by obstruction or irritation in the urinary tract.

Choice B rationale

Increasing fluid intake of 3 to 4 L/day is beneficial for preventing stone formation and enhancing urinary output, but fluid intake changes alone do not address acute renal colic. The urgency lies in alleviating the pain and promoting ureteral relaxation.

Choice C rationale

Tamsulosin (Flomax) 0.4 mg p.o. daily relaxes smooth muscles in the ureter, aiding stone passage, but does not provide immediate pain relief. It is a supportive measure rather than a first-line intervention during acute renal colic.

Choice D rationale

Morphine sulfate (Morphine) 2 mg IV every 4 hours PRN is the correct choice, as it addresses severe pain due to renal colic by acting directly on opioid receptors to block pain transmission. Pain relief improves the client’s comfort and allows further management strategies.

A. Serum electrolytes. B. Complete blood count. C. Blood urea nitrogen. D. Brain natriuretic peptide.

Correct Answer is D

Explanation

Choice A rationale

Serum electrolyte analysis provides insights into fluid and electrolyte balance but does not specifically diagnose heart failure. Electrolyte changes may occur secondary to heart failure but are not definitive markers for the condition.

Choice B rationale

Complete blood count evaluates for anemia or infection, which may contribute to symptomatology but is not diagnostic for heart failure. Heart failure diagnosis focuses on cardiac-specific markers rather than hematologic parameters.

Choice C rationale

Blood urea nitrogen assesses renal function and reflects perfusion status but lacks specificity for heart failure. Although renal dysfunction may occur in advanced heart failure, BNP measurement is more definitive for cardiac assessment.

Choice D rationale

Brain natriuretic peptide (BNP) is a key diagnostic marker for heart failure. Elevated BNP levels occur due to ventricular stretch and strain associated with fluid overload, a hallmark of heart failure. Normal BNP levels are typically <100 pg/mL, with elevated levels strongly suggesting cardiac dysfunction. .

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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?