A nurse is assessing a client who has heart failure and is taking digoxin. Which of the following manifestations should the nurse report to the provider as an indication of digoxin toxicity?
Vomiting.
Dilated pupils.
Bruising.
Peripheral edema.
The Correct Answer is A
Choice A rationale
Vomiting is a common sign of digoxin toxicity. Other symptoms include nausea, confusion, and visual disturbances.
Choice B rationale
Dilated pupils are not a typical sign of digoxin toxicity. Symptoms are more related to gastrointestinal and cardiac effects.
Choice C rationale
Bruising is not directly associated with digoxin toxicity. It may indicate other issues such as coagulopathy.
Choice D rationale
Peripheral edema is not a specific sign of digoxin toxicity. It is more commonly associated with heart failure.
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Correct Answer is ["A","F"]
Explanation
Choice A rationale
Thrombocytopenia, a low platelet count, increases the risk of bleeding and hemorrhage when receiving heparin.
Choice B rationale
Neutropenia, a low white blood cell count, does not directly increase the risk of hemorrhage. It is more related to infection risk.
Choice C rationale
Hypokalemia, low potassium levels, does not directly indicate a risk for hemorrhage. It can cause other complications but not specifically bleeding.
Choice D rationale
Fever is not a direct indicator of hemorrhage risk. It may indicate infection or other inflammatory processes.
Choice E rationale
Hyperglycemia, high blood sugar levels, does not indicate a risk for hemorrhage. It is more related to diabetes management.
Choice F rationale
Dark stools can indicate gastrointestinal bleeding, which is a sign of hemorrhage.
Correct Answer is A
Explanation
Choice A rationale
Asking the client to describe their concerns allows the nurse to understand the client’s perspective and address any misconceptions or fears they may have about the influenza immunization.
Choice B rationale
Contacting the provider is important but should be done after understanding the client’s concerns to provide a comprehensive report.
Choice C rationale
Providing education is essential but should follow understanding the client’s specific concerns to tailor the information effectively.
Choice D rationale
Documenting the refusal is necessary but should be done after addressing the client’s concerns and providing education.