The nurse is caring for a client who was prescribed digoxin. Which manifestations correlate with a digoxin level of 3.0 (Range: 0.8-2.0)? (Select all that apply)

Nausea

Vomiting

Photophobia

Hyperglycemia

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Nausea is a common symptom of digoxin toxicity. Elevated levels of digoxin can cause gastrointestinal disturbances, including nausea.

Choice B reason: Vomiting is also a common symptom of digoxin toxicity. The medication can irritate the stomach and lead to vomiting.

Choice D reason: Hyperglycemia is not typically associated with digoxin toxicity. This symptom is unrelated to the effects of elevated digoxin levels.

Choice E reason: Photophobia is not a common symptom of digoxin toxicity. Symptoms of digoxin toxicity are more likely to be gastrointestinal or cardiovascular in nature.

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Correct Answer is D

Explanation

Choice A reason: Telling the client it is too soon to expect to feel normal and to give it a few more years dismisses her feelings and provides an unrealistic timeline. It is not supportive or empathetic.

Choice B reason: Saying "Really, you look just fine to me. There's no need to feel undesirable" invalidates the client's feelings and does not address her concerns about her body image and sexual desire.

Choice C reason: Suggesting an afternoon at the spa and a facial to make her feel more attractive trivializes the client's emotional and physical experience post-surgery. It does not provide meaningful support or address the underlying issues.

Choice D reason: Expressing interest in how the client's body feels to her validates her feelings and opens up a dialogue for her to share her concerns. This approach is empathetic and allows the nurse to provide better support and address any issues the client might have.

A. The nurse waits 5 minutes between administering prescribed eye drops. B. The nurse leaves the eye shield in place while the client sleeps. C. The nurse is instructing the client not to drive at night. D. The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.

Correct Answer is D

Explanation

Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.

Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.

Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.

Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.

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The nurse is caring for a client who was prescribed digoxin. Which manifestations correlate with a digoxin level of 3.0 (Range: 0.8-2.0)? (Select all that apply)

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Correct Answer is D

Explanation

The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

Correct Answer is D

Explanation

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