A client with heart failure is receiving digoxin. Which finding should indicate to the nurse that the client is experiencing digoxin toxicity?
- A. Constipation
- B. Blurred vision
- C. Bradycardia
- D. Dry cough
Correct Answer: C
Rationale: Bradycardia is a hallmark sign of digoxin toxicity. Digoxin, a medication used to treat heart conditions, can lead to toxicity manifesting as bradycardia. Bradycardia occurs due to the drug's effect on slowing down the heart rate excessively. Constipation (Choice A) is not typically associated with digoxin toxicity. Blurred vision (Choice B) is more commonly linked to visual disturbances caused by digoxin, but it is not a defining sign of toxicity. Dry cough (Choice D) is not a recognized symptom of digoxin toxicity. It is crucial for the nurse to recognize the early signs of digoxin toxicity to prevent serious complications and provide appropriate interventions promptly.
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A client is receiving morphine for pain. Which of the following assessments is the priority?
- A. Urine output
- B. Pupil reaction
- C. Respiratory rate
- D. Bowel sounds
Correct Answer: C
Rationale: The correct answer is C: Respiratory rate. Monitoring the respiratory rate is the priority assessment for a client receiving morphine due to the risk of respiratory depression. Morphine is a potent opioid that can cause respiratory depression, which is a serious adverse effect that can be life-threatening. Assessing the client's respiratory rate is crucial to detect any signs of respiratory depression early and intervene promptly. Assessing urine output is important but not as critical as monitoring for respiratory depression with morphine. Pupil reaction and bowel sounds are also important assessments but do not take precedence over monitoring the respiratory rate when a client is on morphine.
A client has a new prescription for furosemide. Which of the following instructions should the nurse include?
- A. Take the medication with or without food.
- B. Monitor for signs of hypokalemia.
- C. Increase your intake of potassium-rich foods.
- D. Expect an increase in urination.
Correct Answer: D
Rationale: The correct instruction to include when a client is prescribed furosemide is to expect an increase in urination. Furosemide is a diuretic that works by increasing urine production, so it is essential for the client to anticipate and understand this effect. Monitoring for signs of hypokalemia and increasing potassium-rich foods are not directly related to furosemide use. Hypokalemia is a potential side effect of furosemide, so monitoring for it is crucial. Increasing potassium-rich foods can help counteract potassium loss due to diuretic use. Taking furosemide with food is not required, as it can be taken with or without food.
A client has a new prescription for metformin. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Monitor for signs of hyperglycemia.
- C. Increase your fluid intake.
- D. Expect a sweet taste in your mouth.
Correct Answer: C
Rationale: The correct instruction for a client starting metformin is to increase fluid intake. Metformin commonly causes gastrointestinal discomfort, and increasing fluid intake can help alleviate this side effect. Instructing the client to take the medication with food (Choice A) rather than on an empty stomach is recommended to reduce gastrointestinal side effects. Monitoring for signs of hyperglycemia (Choice B) is not directly related to metformin but rather to low blood sugar. Expecting a sweet taste in the mouth (Choice D) is not a common side effect of metformin.
A nurse is assessing a client who has been taking levothyroxine for hypothyroidism. Which of the following findings should the nurse report to the provider?
- A. Weight loss
- B. Insomnia
- C. Heat intolerance
- D. Dry skin
Correct Answer: C
Rationale: The correct answer is C: Heat intolerance. Heat intolerance is a sign of levothyroxine toxicity and requires immediate attention. Weight loss may actually be an expected outcome of levothyroxine therapy as it can help regulate metabolism in hypothyroidism. Insomnia can occur as a side effect of levothyroxine but is not as concerning as heat intolerance. Dry skin is a common symptom of hypothyroidism and may improve with levothyroxine therapy, so it is not a priority finding to report to the provider.
A healthcare professional is reviewing laboratory results for a client who has been taking carbamazepine. Which of the following findings should the healthcare professional report to the provider?
- A. WBC count 3,000/mm3
- B. Platelet count 150,000/mm3
- C. Hemoglobin 14 g/dL
- D. Serum potassium 4.5 mEq/L
Correct Answer: A
Rationale: A WBC count of 3,000/mm3 indicates leukopenia, a serious side effect of carbamazepine. Leukopenia can increase the risk of infections due to decreased white blood cell count, which is important to report to the provider for further evaluation and management. Platelet count within normal range (choice B), hemoglobin level within normal range (choice C), and serum potassium level within normal range (choice D) are not directly associated with carbamazepine use and do not require immediate reporting as they do not indicate a serious adverse effect.
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