A client receiving intravenous nitroglycerin at 20
mcg/min complains of dizziness. Nursing
assessment reveals a blood pressure of 85/40 mm
Hg, heart rate of 110 beats/min, and respiratory rate
of 16 breaths/min. What is the nurse's priority action?
a. Assess the client's lung sounds.
b. Decrease the intravenous nitroglycerin by 10
mcg/min.
c. Stop the nitroglycerin infusion for 1 hour, and then
restart.
,d. Recheck the client's vital signs in 15 minutes but
continue the infusion. - ....ANSWER...b. Decrease the
intravenous nitroglycerin by 10 mcg/min.
The nurse is monitoring a client taking digoxin
(Lanoxin) for treatment of heart failure. Which
assessment finding indicates a therapeutic effect of
the drug?
a. Heart rate 110 beats per minute
b. Heart rate 58 beats per minute
c. Urinary output 40 mL/hr
d. Blood pressure 90/50 mm Hg - ....ANSWER...b.
Heart rate 58 beats per minute
A client's serum digoxin level is drawn, and it is 0.4
ng/mL. What is the nurse's priority action?
a. Administer ordered dose of digoxin.
b. Hold future digoxin doses.
c. Administer potassium.
d. Call the health care provider. - ....ANSWER...a.
Administer ordered dose of digoxin.
,A client is taking digoxin (Lanoxin) 0.25 mg and
furosemide (Lasix) 40 mg. When the nurse enters
the room, the client states, "There are yellow halos
around the lights." Which action will the nurse take?
a. Evaluate digoxin levels.
b. Withhold the furosemide
c. Administer potassium.
d. Document the findings and reassess in 1 hour. -
....ANSWER...a. Evaluate digoxin levels.
Which assessment finding will alert the nurse to
suspect early digitalis toxicity?
a. Loss of appetite with slight bradycardia
b. Blood pressure 90/60 mm Hg
c. Heart rate 110 beats per minute
d. Confusion and diarrhea - ....ANSWER...a. Loss of
appetite with slight bradycardia
The nurse reviews a client's laboratory values and
finds a digoxin level of 10 ng/mL and a serum
, potassium level of 5.9 mEq/L. What is the nurse's
primary intervention?
a. To administer atropine
b. To administer digoxin immune FAB
c. To administer epinephrine
d. To administer Kayexalate - ....ANSWER...b. To
administer digoxin immune FAB
A client is to begin treatment for short-term
management of heart failure with milrinone lactate
(Primacor). What is the priority nursing action?
a. Administer digoxin via IV infusion with the
Primacor.
b. Administer Lasix (furosemide) via IV infusion after
the Primacor.
c. Monitor blood pressure continuously.
d. Maintain an infusion of lactated Ringers with
Primacor infusion. - ....ANSWER...c. Monitor blood
pressure continuously.
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