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Which data would cause the nurse to question administering digoxin to a client diagnosed with congestive heart failure?
- A. The potassium level is 3.2 mEq/L.
- B. The digoxin level is 1.2 mcg/mL.
- C. The client's apical pulse is 64.
- D. The client denies yellow haze.
Correct Answer: A
Rationale: Hypokalemia (K+ 3.2, A) increases digoxin toxicity risk, warranting caution. Digoxin level 1.2 (B) is therapeutic, pulse 64 (C) is normal, and no yellow haze (D) is expected.
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After hearing the nurse's instructions about activity restrictions and the potentially dangerous consequences of certain activities, the client correctly states the importance for avoiding which of the following?
- A. Carrying groceries from the car
- B. Straining during a bowel movement
- C. Bathing in warm water
- D. Having sexual intercourse
Correct Answer: B
Rationale: Straining during a bowel movement increases intrathoracic pressure, raising cardiac workload and MI risk.
When the nurse is about to administer digoxin to a client, the client says, 'I think I need to see the eye doctor. Things seem to look kind of green today.' The nurse takes his vital signs, which are blood pressure = 150/94, pulse = 60 bpm, and respirations = 28. What is the most appropriate initial action for the nurse to take?
- A. Administer the medication and record the findings on his chart
- B. Withhold the digoxin and report to the charge nurse
- C. Request an appointment with the ophthalmologist
- D. Reassure the client that he is having a normal reaction to his medication
Correct Answer: B
Rationale: Visual disturbances, such as seeing a green or yellow halo, are signs of digoxin toxicity. The nurse should withhold the medication and report to the charge nurse for further evaluation.
The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data support this concept?
- A. The client has a large abdomen and a positive tympanic wave.
- B. The client has paroxysmal nocturnal dyspnea.
- C. The client has 2+ glucose in the urine.
- D. The client has a comorbid condition of myocardial infarction.
Correct Answer: B
Rationale: PND (B) indicates fluid overload in CHF, supporting impaired perfusion. Large abdomen (A) suggests ascites, glucosuria (C) is diabetes-related, and MI (D) is a cause, not a symptom.
The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?
- A. Do you have a daily bowel movement?'
- B. Do you get yearly chest x-rays (CXRs)?'
- C. Are you sexually active?'
- D. Have you had any weight change?'
Correct Answer: D
Rationale: Weight change (D) may indicate fluid retention or malnutrition, relevant to CAD management. Bowel movements (A), CXRs (B), and sexual activity (C) are less directly related.
Which assessment finding would support the possibility of right-sided heart failure?
- A. Jugular vein distention
- B. Bradycardia
- C. Dry, hacking cough
- D. Flushed, red face
Correct Answer: A
Rationale: Jugular vein distention indicates increased venous pressure, typical of right-sided heart failure.