Nokea
A client comes to the clinic complaining of weakness and drowsiness. He states, 'I just get so tired sometimes that Lean't do what I want to do.' The client is receiving digoxin as part of the treatment for heart failure. Which nursing diagnosis would the nurse most likely identify?
- A. Risk for Injury
- B. Activity Intolerance
- C. Decreased Cardiac Output
- D. Imbalanced Nutrition: Less Than Body Requirements
Correct Answer: B
Rationale: Based on the client's statement and complaints, the nurse would most likely identify a nursing diagnosis of Activity Intolerance. Risk for Injury might be appropriate if the client complained of dizziness or if his complaints affected his ambulation. There is no evidence to support a nursing diagnosis of Decreased Cardiac Output or Imbalanced Nutrition.
You may also like to solve these questions
Which of the following is true with regard to oral administration of cardiotonic drugs? Select all that apply.
- A. Capsule doses are less absorbed.
- B. Alternating between oral dosage forms is avoided.
- C. Tablets can be crushed and mixed with food or fluids.
- D. Oral dosage forms can be administered without regard to meals.
- E. The recommended dosage of the capsules is 80% more than that of tablets.
Correct Answer: B,C,D
Rationale: Oral preparations can be given without regard to meals. Tablets can be crushed and mixed with food or fluids if the patient has difficulty swallowing. Do not alternate between the dosage forms (i.e., tablets and capsules); these dosages are not the same. Owing to better absorption, the recommended dosage of the capsules is 80% of the dosage for tablets and elixir.
A nursing instructor is conducting a class on heart failure and the events that occur. The instructor describes which of the following as a result of increases in neurohormonal activity that occur with heart failure? Select all that apply.
- A. Decreased secretion of catecholamines
- B. Remodeling of the cardiac muscle cells
- C. Hypertrophy of the heart
- D. Increased need for oxygen
- E. Cardiac necrosis
Correct Answer: B,C,D,E
Rationale: Increased catecholamines lead to increases in neurohormonal activity that cause remodeling of the cardiac muscle cells, leading to hypertrophy of the heart, increased need for oxygen, and cardiac necrosis, which worsen the heart failure.
After receiving a loading dose of milrinone (Primacor), the nurse would assess the client for which of the following as most likely? Select all that apply.
- A. Hypertension
- B. Angina
- C. Hyperkalemia
- D. Headache
- E. Insomnia
Correct Answer: B,D
Rationale: The adverse reactions most likely to occur after the administration of milrinone (Primacor) to a client are ventricular arrhythmias, hypotension, angina, chest pain, headache, and hypokalemia.
A nurse checks the serum digoxin level of a client and finds it to be increased. Which of the following would the nurse identify as possibly associated with this increase?
- A. Colestipol (Colestid)
- B. Verapamil (Calan)
- C. Clarithromycin (Biaxin)
- D. Calcium carbonate (Maalox)
- E. Spironolactone (Aldactone)
Correct Answer: B,C,E
Rationale: Increased serum digoxin levels can occur with verapamil, clarithromycin, and spironolactone. Antacids, such as calcium carbonate, and colestipol cause a decrease in serum digoxin levels.
A nurse is preparing to administer a cardiotonic drug via IM injection based on the understanding of which of the following about this route? Select all that apply.
- A. Appropriate when IV access is not available
- B. Site massage necessary after injection
- C. Not the recommended parenteral route
- D. Amount given no more than 2 \mathrm{~mL}
- E. Injection deep into the muscle
Correct Answer: A,B,D,E
Rationale: IM injection is not recommended for cardiotonic drugs yet, but they may be given as an IM injection when needed urgently and no IV access is available. When administering a cardiotonic drug IM, the nurse should give the injection deep in the muscle and follow with massage to the site. No more than 2 \mathrm{~mL} should be injected IM.