M Q&A
A client with heart failure is being given furosemide (Lasix) and digoxin (Lanoxin). The
client calls the nurse and complains of anorexia and nausea. Which action should the
nurse take first? - (correct answer)D. Checking the result of laboratory testing for
potassium on the sample drawn 3 hours ago.
Rationale: Anorexia and nausea are symptoms commonly associated with digoxin
toxicity, which is compounded by hypokalemia. Early clinical manifestations of digoxin
toxicity include anorexia and mild nausea, but they are frequently overlooked or not
associated with digoxin toxicity. Hallucinations and any change in pulse rhythm, color
vision, or behavior should be investigated and reported to the healthcare provider. The
nurse should first check the results of the potassium level, which will provide additional
when the nurse calls the physician, an important follow-up action. The nurse should also
check the digoxin reading if one is available. The nurse would not administer an
antiemetic without further investigating the client's problem. Because digoxin toxicity is
suspected, the nurse would withhold the digoxin until the physician has been consulted.
The nurse would not discontinue a medication without a prescription to do so.
A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened,
warm, painful, and slightly edematous near the insertion point of the catheter. On the
basis of this assessment, the nurse first: - (correct answer)A.Removes the IV catheter.
Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may
be indicated by client discomfort at the site or by redness, warmth, and swelling in the
area of the catheter. The IV catheter should be removed and a new IV line inserted at a
different site. Slowing the rate of infusion and checking for loose catheter connections
are not correct responses. The healthcare provider would be notified if phlebitis were to
occur, but this is not the initial action.
A client is taking a folic acid supplement (Folate). Which of the following laboratory
parameters does the nurse use to evaluate the effectiveness of this therapy? Select all
that apply. - (correct answer)B.Hemoglobin.
Rationale: Folic acid, necessary for red blood cell production, is classified as a vitamin
and as an antianemic agent. Both hematocrit and hemoglobin are appropriate
A client with heart failure is being given furosemide (Lasix) and digoxin (Lanoxin). The
client calls the nurse and complains of anorexia and nausea. Which action should the
nurse take first? - (correct answer)D. Checking the result of laboratory testing for
potassium on the sample drawn 3 hours ago.
Rationale: Anorexia and nausea are symptoms commonly associated with digoxin
toxicity, which is compounded by hypokalemia. Early clinical manifestations of digoxin
toxicity include anorexia and mild nausea, but they are frequently overlooked or not
associated with digoxin toxicity. Hallucinations and any change in pulse rhythm, color
vision, or behavior should be investigated and reported to the healthcare provider. The
nurse should first check the results of the potassium level, which will provide additional
when the nurse calls the physician, an important follow-up action. The nurse should also
check the digoxin reading if one is available. The nurse would not administer an
antiemetic without further investigating the client's problem. Because digoxin toxicity is
suspected, the nurse would withhold the digoxin until the physician has been consulted.
The nurse would not discontinue a medication without a prescription to do so.
A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened,
warm, painful, and slightly edematous near the insertion point of the catheter. On the
basis of this assessment, the nurse first: - (correct answer)A.Removes the IV catheter.
Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may
be indicated by client discomfort at the site or by redness, warmth, and swelling in the
area of the catheter. The IV catheter should be removed and a new IV line inserted at a
different site. Slowing the rate of infusion and checking for loose catheter connections
are not correct responses. The healthcare provider would be notified if phlebitis were to
occur, but this is not the initial action.
A client is taking a folic acid supplement (Folate). Which of the following laboratory
parameters does the nurse use to evaluate the effectiveness of this therapy? Select all
that apply. - (correct answer)B.Hemoglobin.
Rationale: Folic acid, necessary for red blood cell production, is classified as a vitamin
and as an antianemic agent. Both hematocrit and hemoglobin are appropriate
