The nurse prepares to administer digoxin 0.125 mg PO to a client who has chronic heart failure. The laboratory report reveals a digoxin level of 2.5 mg/mL. Which nursing action is most appropriate at this time?

Assess the apical pulse and if above 60 beats/minute administer the dose.

Administer 0.25 mcg and potassium 20 mEq IV.

Withhold the medication and notify the healthcare provider of the digoxin level.

Administer the digoxin with a potassium supplement.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is incorrect. Assessing the apical pulse is not enough to determine if the client is safe to receive digoxin. The client's digoxin level is already above the therapeutic range of 0.5 to 2 ng/mL¹² and giving another dose could increase the risk of toxicity and arrhythmias.

Choice B reason: This is incorrect. Administering 0.25 mcg of digoxin and potassium 20 mEq IV is not appropriate for this client. The client does not need more digoxin or potassium, as both could worsen the client's condition. Potassium levels should be monitored closely in clients taking digoxin, as low or high levels can affect the drug's action and toxicity³.

Choice C reason: This is correct. Withholding the medication and notifying the healthcare provider of the digoxin level is the most appropriate action for this client. The client's digoxin level is dangerously high and could cause serious adverse effects such as nausea, vomiting, vision changes, bradycardia, and cardiac arrest³. The healthcare provider may order to stop digoxin temporarily, adjust the dose, or prescribe an antidote such as digoxin immune fab⁴.

Choice D reason: This is incorrect. Administering the digoxin with a potassium supplement is not advisable for this client. The client's digoxin level is already too high and adding potassium could increase the risk of hyperkalemia, which can impair the heart's electrical activity and lead to cardiac arrest³. Potassium supplements should only be given to clients with digoxin-induced hypokalemia, and only under the supervision of the healthcare provider³..

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Correct Answer is D

Explanation

Choice A reason: I should continue to read the labels of foods I select at the grocery store is not a statement that indicates a need for further clarification by the nurse. This statement shows that the client understands the importance of choosing foods that are low in sodium, fat, and calories, which can help lower blood pressure and prevent complications.

Choice B reason: Keeping my blood pressure under control reduces my risk for a heart attack is not a statement that indicates a need for further clarification by the nurse. This statement shows that the client understands the benefits of pharmacologic therapy for hypertension, which can prevent or delay the development of cardiovascular disease.

Choice C reason: When I get out of bed in the morning, I should first sit for a few minutes and then stand is not a statement that indicates a need for further clarification by the nurse. This statement shows that the client understands how to prevent or minimize orthostatic hypotension, which is a possible side effect of some anti-hypertensive medications.

Choice D reason: I will be able to stop my anti-hypertensive medication when my blood pressure is normal is a statement that indicates a need for further clarification by the nurse. This statement shows that the client has a misconception about the nature and duration of pharmacologic therapy for hypertension. The nurse should explain that hypertension is a chronic condition that requires lifelong treatment and monitoring, and that stopping the medication abruptly can cause a rebound increase in blood pressure and increase the risk of complications.

A. Decreased hair is most likely a hereditary condition and nail changes are related to fungus. B. A blood clot may be forming and the client needs immediate intervention. C. Decreased oxygen to the tissues causes changes in hair growth and nail texture. D. Depending on the client's age, the findings may be normal.

Correct Answer is D

Explanation

Choice A reason: Decreased hair is most likely a hereditary condition and nail changes are related to fungus is not the statement that describes the cause of this finding. This statement is not based on evidence and does not explain the relationship between peripheral vascular disease and the observed changes in the legs and feet.

Choice B reason: A blood clot may be forming and the client needs immediate intervention is not the statement that describes the cause of this finding. This statement is an alarmist and inaccurate interpretation of the finding. A blood clot would cause more acute and severe symptoms, such as pain, swelling, redness, and warmth in the affected area.

Choice C reason: Decreased oxygen to the tissues causes changes in hair growth and nail texture is the statement that describes the cause of this finding. This statement is based on the pathophysiology of peripheral vascular disease, which is a chronic condition that reduces the blood flow to the extremities due to atherosclerosis or inflammation of the blood vessels. The reduced blood flow leads to tissue ischemia and necrosis, which can manifest as hair loss, thickening and yellowing of the nails, skin ulcers, and gangrene.

Choice D reason: Depending on the client's age, the findings may be normal is not the statement that describes the cause of this finding. This statement is a vague and dismissive response that does not address the underlying problem of peripheral vascular disease. The findings are not normal for any age group and require further assessment and intervention.

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The nurse prepares to administer digoxin 0.125 mg PO to a client who has chronic heart failure. The laboratory report reveals a digoxin level of 2.5 mg/mL. Which nursing action is most appropriate at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement, made by a client receiving pharmacologic therapy for hypertension, indicates a need for further clarification by the nurse?

Correct Answer is D

Explanation

The nurse, who is assessing a client with peripheral vascular disease, notes that the client has no hair on the legs and has thick toenails. Which statement describes the cause of this finding?

Correct Answer is D

Explanation

The nurse is teaching a client with hypertension about the prescribed hydrochlorothiazide 10 mg PO daily. Which statement, made by the client, would indicate that the teaching has been effective? "I will:

The client diagnosed with primary hypertension says, "I don't know why the doctor is worried about my blood pressure. I am feeling just fine." Which statement by the nurse would be the most appropriate?

A client with coronary artery disease complains of chest pain while brushing their teeth in the bathroom. Which action should the nurse implement first?

The nurse is aware that the goal of using diltiazem 30 mg PO bid in the collaborative plan of care for a client diagnosed with variant (Prinzmetal's) angina is to:

The nurse instructs a client diagnosed with hypertension and coronary artery disease who has been given a new prescription for carvedilol 6.25 mg PO bid to:

The nurse is caring for a client who just returned to the nursing unit following a cardiac angiogram and stent insertion. Which action should the nurse implement first?

The nurse is reviewing the laboratory test results of a client with long-standing hypertension. Which result would be of most concern to the nurse?

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