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 A

Explanation

Choice A rationale

Stones lodged in the ureter cause severe, colicky pain due to intense peristaltic waves attempting to dislodge the obstruction. The pain often radiates down the thigh and groin as the ureter's path follows these areas. Additionally, urinary retention or frequent urges with minimal voiding occurs due to irritation and partial blockage, confirming ureteral stone involvement.

Choice B rationale

While some stones may pass spontaneously, timing varies widely depending on size, location, and hydration levels. Pain and obstruction may persist longer than a few hours, making this statement misleading without further assessment.

Choice C rationale

Bladder stones may cause lower abdominal pain, frequency, and hematuria but do not typically involve radiating pain to the groin or thigh. The described symptoms strongly suggest ureteral obstruction rather than bladder involvement.

Choice D rationale

While procedural removal is an option for large or immovable stones, initial approaches often include pain control, hydration, and medical expulsive therapy. Surgical intervention is not the first-line explanation unless conservative management fails.

A. Assess for hypotension. B. Assess for distention above the pubis area. C. Monitor the client's laboratory values for hypernatremia. D. Maintain strict intake and output records.

Correct Answer is D

Explanation

Choice A rationale

Hypotension is not a typical sign of fluid overload. Fluid overload often presents with hypertension due to increased circulatory volume. Monitoring blood pressure is essential, but hypotension does not reliably indicate fluid overload. This option does not align with scientific understanding of fluid overload symptoms.

Choice B rationale

Distention above the pubis area suggests urinary retention or bladder distension rather than fluid overload. While important to assess, it does not directly indicate fluid overload. This symptom is more related to mechanical issues than systemic fluid imbalance and volume overload.

Choice C rationale

Hypernatremia is not a sign of fluid overload. Fluid overload typically results in dilutional hyponatremia, where excessive fluids lower sodium levels. Monitoring sodium levels is useful, but hypernatremia would suggest dehydration or other conditions, not excess fluid volume. This choice is inconsistent with scientific knowledge.

Choice D rationale

Maintaining strict intake and output records is a fundamental approach to monitoring fluid balance. Accurate measurements of fluid intake and output help detect fluid overload early. This method directly correlates with assessing excess fluid volume in clinical practice. It is a reliable, evidence-based intervention for monitoring fluid status. .

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 assessing a client suspected of having renal calculi who reports severe, wavelike pain that radiates down the thigh and to the genital area and a sensation of needing to void, but only small amounts are voided.The nurse should explain which of the following information to the client?

Correct Answer is A

Explanation

The nurse is providing postoperative care for a male client who had a transurethral resection of the prostate (TURP) 4 hours ago and has continuous irrigation.Which of the following actions should the nurse take to monitor the client for fluid overload?

Correct Answer is D

Explanation

The nurse has taught a client with urinary incontinence about managing the problem.Which of the following statements by the client would indicate the need for more teaching?

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 the outcome of the treatment goals for a client with heart failure.Which of the following would be the best query for the nurse to ask?

The nurse is caring for a client who is in heart failure and weighs 176 pounds. The client is to receive prescribed dobutamine 10 mcg/kg/minute. The nurse has available 1,000 mg in 250 mL of 0.9% normal saline. How many mL per hour should the nurse administer to the client?

The nurse is teaching a client about preventing symptoms of thalassemia.Which of the following information should the nurse include in the teaching?

The nurse is caring for a client who has thrombocytopenia.Which of the following will the nurse administer for this disorder?

The nurse is planning care for a female client with a lower urinary tract infection (UTI). Which of the following interventions should be the priority for the nurse to include in the client's plan of care?

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?