Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from an adolescent client who takes digoxin.
The nurse should monitor the client for which of the following adverse effects?
A. Yellow Sclera.
Choice A is wrong because yellow sclera is not an adverse effect of digoxin. It can be a sign of jaundice or liver disease.
B. Blurred vision.
Blurred vision is a common adverse effect of digoxin that affects the eyes and the central nervous system. It can also cause yellow or green vision, halos around lights, and night blindness.
C. Frequent swallowing.
Choice C is wrong because frequent swallowing is not an adverse effect of digoxin. It can be a sign of dysphagia or throat irritation.
D. Bleeding gums.
Choice D is wrong because bleeding gums is not an adverse effect of digoxin. It can be a sign of gingivitis or coagulation disorder. Other adverse effects of digoxin include nausea, vomiting, diarrhea, lower stomach pain, dizziness, drowsiness, headache, weakness, confusion, depression, anxiety, hallucinations, expressed fear of impending death, rash, weight loss, loss of appetite, and various cardiac arrhythmias.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Capstone Proctored Comprehensive Assessment 2020 B. Take the full exam now
Full Explanation
Blurred vision is a common adverse effect of digoxin that affects the eyes and the central nervous system. It can also cause yellow or green vision, halos around lights, and night blindness.
Choice A is wrong because yellow sclera is not an adverse effect of digoxin. It can be a sign of jaundice or liver disease.
Choice C is wrong because frequent swallowing is not an adverse effect of digoxin.
It can be a sign of dysphagia or throat irritation.
Choice D is wrong because bleeding gums is not an adverse effect of digoxin. It can be a sign of gingivitis or coagulation disorder.
Other adverse effects of digoxin include nausea, vomiting, diarrhea, lower stomach pain, dizziness, drowsiness, headache, weakness, confusion, depression, anxiety, hallucinations, expressed fear of impending death, rash, weight loss, loss of appetite, and various cardiac arrhythmias.
Some of these effects can indicate digoxin toxicity and require immediate medical attention.
Normal ranges for serum digoxin levels are 0.5 to 2 ng/mL for adults and 0.8 to 2 ng/mL for children.
Serum digoxin levels should be monitored regularly to avoid overdose or underdose.
Similar Questions
A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP).
Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?
A. The task involves making ongoing judgments about client data.
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
B. The task is within the AP’s range of function to perform.
Choice B is wrong because the task is within the AP’s range of function to perform. This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
C. The task can be performed in the same manner for most clients.
Choice C is wrong because the task can be performed in the same manner for most clients. This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
D. The task requires a specific sequence of steps.
Choice D is wrong because the task requires a specific sequence of steps. This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
Full Explanation
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
Choice B is wrong because the task is within the AP’s range of function to perform.
This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
Choice C is wrong because the task can be performed in the same manner for most clients.
This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
Choice D is wrong because the task requires a specific sequence of steps.
This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
A nurse is collecting data from a 24-month-old toddler during an annual physical examination.
Which of the following findings should the nurse report to the provider?
A. Can draw a circle.
Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.
B. Has a vocabulary of four words.
Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.
C. Jumps with both feet.
Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.
D. Weighs 12 kg (26.5 Ib).
Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.
Full Explanation
Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.
Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.
Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.
Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.
A nurse is reinforcing teaching with a client who has a new prescription for verapamil.
Which of the following instructions should the nurse include in the teaching?
A. Expect palpitations for 2 days.
Choice A is wrong because palpitations are not an expected side effect of verapamil, but rather a sign of a possible overdose or a serious heart problem that requires medical attention.
B. Change positions slowly.
Verapamil is a calcium channel blocker that can lower blood pressure and cause dizziness or fainting, especially when standing up from a sitting or lying position. Changing positions slowly can help prevent these symptoms.
C. Take the medication on an empty stomach.
Choice C is wrong because verapamil should be taken with food or milk to avoid stomach upset and increase absorption.
D. Increase calorie intake to minimize weight loss.
Choice D is wrong because verapamil does not cause weight loss, but rather weight gain as a possible side effect. Increasing calorie intake is not necessary and may worsen other health conditions such as diabetes or high cholesterol.
Full Explanation
Verapamil is a calcium channel blocker that can lower blood pressure and cause dizziness or fainting, especially when standing up from a sitting or lying position. Changing positions slowly can help prevent these symptoms.
Choice A is wrong because palpitations are not an expected side effect of verapamil, but rather a sign of a possible overdose or a serious heart problem that requires medical attention.
Choice C is wrong because verapamil should be taken with food or milk to avoid stomach upset and increase absorption.
Choice D is wrong because verapamil does not cause weight loss, but rather weight gain as a possible side effect.
Increasing calorie intake is not necessary and may worsen other health conditions such as diabetes or high cholesterol.