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 E
Explanation
Choice A rationale
Hypercalcemia is not typically a risk in the emergency department unless the patient has a specific condition that causes elevated calcium levels.
Choice B rationale
Hypotension can occur in the emergency department, especially in cases of shock or severe dehydration, but it is not the most common risk.
Choice C rationale
Hypokalemia can occur, particularly in patients with certain medical conditions or those taking diuretics, but it is not the most common risk.
Choice D rationale
Hypernatremia can occur, especially in patients with dehydration or certain medical conditions, but it is not the most common risk.
Choice E rationale
Hypoglycemia is a common risk in the emergency department, especially in patients with diabetes or those who have not eaten for an extended period.
Correct Answer is C
Explanation
Choice A rationale
A standing prescription is an order that applies to all patients who meet certain criteria and is not specific to a single administration. It is used for routine treatments and does not apply to a one-time pre-transfusion medication.
Choice B rationale
A stat prescription is an urgent order that requires immediate administration, typically within minutes. It is used for emergency situations and does not apply to a pre-transfusion medication given one hour before the procedure.
Choice C rationale
A single prescription is a one-time order for a specific medication to be given at a specific time. In this case, diphenhydramine 50 mg by mouth once, one hour prior to transfusion, fits the definition of a single prescription.
Choice D rationale
A PRN (pro re nata) prescription is an order for medication to be given as needed based on the patient’s condition. It is not applicable to a scheduled pre-transfusion medication.