the nurse is assessing a client who has a prescription for digoxin lanoxin which finding indicates that the client is at risk for digoxin toxicity
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Nursing Elites

HESI RN

HESI RN CAT Exam Quizlet

1. The nurse is assessing a client who has a prescription for digoxin (Lanoxin). Which finding indicates that the client is at risk for digoxin toxicity?

Correct answer: D

Rationale: A low serum potassium level increases the risk of digoxin toxicity. Digoxin toxicity is more likely to occur in individuals with low potassium levels because potassium is crucial for proper heart function. A heart rate of 60 beats per minute, blood pressure of 120/80 mm Hg, and respiratory rate of 18 breaths per minute are within normal ranges and do not directly indicate an increased risk of digoxin toxicity.

2. A client is receiving a low dose of dopamine (Intropin) IV for the treatment of hypotension. Which indicator reflects that the medication is having the desired effect?

Correct answer: C

Rationale: Increased blood pressure is the desired effect of administering dopamine (Intropin) to treat hypotension. Dopamine acts by stimulating adrenergic receptors, leading to vasoconstriction and increased cardiac output. This results in an elevation of blood pressure. Choices A, B, and D are incorrect as they do not directly reflect the therapeutic action of dopamine in treating hypotension. Increased heart rate may indicate the body compensating for low blood pressure, increased urinary output is more related to kidney function, and increased respiratory rate is often seen in response to respiratory issues, not the action of dopamine on hypotension.

3. At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?

Correct answer: B

Rationale: The correct answer is B. Monthly breast self-exams are essential for early detection of breast cancer. While annual clinical breast exams and mammograms are important, monthly self-exams enhance early detection by helping women become familiar with their breasts and notice any changes. Choice A is incorrect as it does not address the importance of self-exams. Choice C is incorrect as it prematurely commends without ensuring the woman is conducting self-exams. Choice D is incorrect as it provides inaccurate information about the frequency of mammograms needed.

4. A client with a history of heart failure is admitted to the hospital with worsening dyspnea. The nurse notes that the client has a productive cough with pink, frothy sputum. What action should the nurse take first?

Correct answer: A

Rationale: In a client with heart failure presenting with worsening dyspnea and pink, frothy sputum (indicating pulmonary edema), the priority action for the nurse is to administer oxygen. Oxygen therapy helps improve oxygenation and alleviate dyspnea by increasing the oxygen supply to the lungs. Performing chest physiotherapy, elevating the head of the bed, or obtaining a sputum specimen are not the initial actions indicated in this situation and may delay addressing the client's immediate need for improved oxygenation.

5. A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?

Correct answer: D

Rationale: The correct way to collect a 24-hour urine specimen is to discard the first morning void and then start the collection. Choice A is incorrect because refrigeration is not typically necessary for a 24-hour urine specimen. Choice B is incorrect as the client needs to discard the first void. Choice C is incorrect; while collecting urine for 24 hours is correct, keeping it on ice is not standard procedure.

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