cardiac- Pharm Exam 2

What *OTC medication* should the nurse warn the hypertensive patient about that can raise BP?

*decongestants* can raise BP

What are the effects of hydrochlorothiazide (HCTZ) on electrolytes

*decrease* sodium and potassium *increase* glucose, uric acid, and cholesterol/triglycerides

E. Nuff was recently diagnosed with HF. He stopped taking his medication because they made him feel tired He states he hasn't been sleeping well, that he can really only fall asleep stacked up on pillows or in a recliner, and that he has been coughing a lot. -What breath sound would you anticipate? -What would you anticipate would happen with the patients weight? -What medication class would you anticipate being ordered for this patient to help improve his breathing?

-Crackles -Patient will gain weight -lasix should be ordered

Which medication is first-line treatment for hyperlipidemia?

-Statins

Which two medications classes are used for the treatment of angina?

-beta blockers -calcium channel blockers

Both Resin and Cholestyramine do what?

-binds with bile acids in intestine -leaves body via feces *Resn is too large to reabsorb*

What are nursing indications for digoxin?

-check apical pulse for 1 min before giving (must be >60. -two nurse check -monitor potassium (decreased K+ (diuretics) can cause dig toxicity)

beta blockers end in...

-lol (atenolol, metoprolol, timolol)

What are the administration time rules for altepase

-must give within 12 hours of *MI* onset -must give 3 hours within *stroke* onset

Alpha blocker end in...

-osin

MOST Calcium Channel Blockers end in...

-pine

Ace Inhibitors end in...

-pril (enalapril, lisinopril)

ARBs end in...

-sartan

HMG-CoA Reductase Inhibitors end in....

-statin (atorvastatin, pravastatin)

Which of the following diuretics is contraindicated in pre-eclampsia or pregnancy?

-thiazide

Name some bleeding precautions wth lovenox

-use soft brissel toothbrush -no rectal temps/meds -use electrical razors -avoid extra injections/sticks

Signs of digoxin toxicity

-visual disturbance (halos, blurring) -bradycardia -vomiting

Therapeutic range for digoxin

0.8-2 mg/L

What are 4 groups of diuretics discussed in this section?

1. Loop 2. Thiazide 3. Potassium Sparing 4. Osmotic diuretic

Name 2 bile acid sequestrants

1. Resin (sequestrants) 2. Cholestyramine (Questran)

What are 4 uses for beta blockers?

1. antihypertensive 2. antianginals (dec O2 demand on heart 3. antidysrhythmic (dec HR to override dysrhythmias 4. Ocular HTN/glaucoma (timolol)

if patient is "annoyed" with ace inhibitor (-pril) side effects, they should be given??

ARB (-sartan)

A healthcare provider prescribes enoxaparin 30 mg subcutaneously daily. Which measure would the nurse take when administering this medication?

Administer in the abdomen rationale: Enoxaparin specifically targets blood clots throughout the body and carries a lower risk of hemorrhage than that associated with the drugs heparin and warfarin. Enoxaparin is administered once a day through a subcutaneous injection site around the naval. Enoxaparin should be injected into the fatty tissue only, which is why the abdomen is the recommended injection site. Avoid administering in a muscle. Manufacturer recommendations indicate the air pocket from prepackaged syringes not be removed before administration. Rubbing the site is contraindicated, as it can cause bruising. There are no recommendations to push this subcutaneous medication over 2 minutes.

The healthcare provider prescribes enoxaparin to be administered subcutaneously daily to a client who had a total knee replacement. To ensure client safety, which measure would the nurse take when administering this medication?

Administer in the abdomen area only. Rationale: The preferred site for enoxaparin administration is the abdomen. According to package directions, the air pocket in the prepackaged syringe should not be removed. Rubbing the injection site also is contraindicated. Subcutaneous injections should not be given over 2 minutes.

Nursing student asks how to remove the air bubble from the lovenox injector before administering. What education should be done?

Air bubble in lovenox injectors should not be removed. Rationale: seals medication in tissues. Prevents spread to subq space, and decreases hematomas.

What is important for the nurse to do before giving altepase?

Assess patient history for head injury Rationale: if they have had a head injury it puts them at risk of a brain bleed. They can not have it.

Which instructions should the nurse include in the teaching plan for a client who will be taking simvastatin when discharged? Select all that apply.

Avoid prolonged exposure to the sun. Schedule regular ophthalmic examinations. Contact your healthcare provider if skin becomes gray-bronze. Rationale: Simvastatin increases photosensitivity; the client should avoid sun exposure and use sunblock. The client should be monitored for the adverse effects of glaucoma and cataracts. Gray-bronze skin and unexplained muscle pain are signs of rhabdomyolysis. Rhabdomyolysis, a life-threatening response, is the disintegration of muscle associated with myoglobin in the urine. Simvastatin does not affect levels of potassium. The medication is most effective when taken at bedtime because cholesterol synthesis is highest at night.

What are *contraindications* with beta blockers?

Bradycardia cardiogenic shock heart block

Which of the following medications relax coronary artery spasm & peripheral arterioles?

Calcium Channel Blockers

What should we warn the patient when administering lovenox

Can burn when injected

Vasodilating beta blockers and their side effects

Carvedilol (NEW) labetolol nebivolol SE: alpha 1 blocking effects

A beta-blocker, atenolol, is prescribed for a client with moderate hypertension. What information should the nurse include when teaching the client about this medication? Select all that apply.

Change to standing positions slowly. Count the pulse before taking the medication. Mild weakness and fatigue are common side effects. Rationale: A side effect of this medication is orthostatic hypotension. The client should be advised to move to a standing position slowly to allow the vasomotor response of the body to adjust to the new position. The rate of the pulse should be taken before administering the medication; ventricular dysrhythmias and heart block may occur. Mild weakness and fatigue, as well as dizziness and depression, are side effects of this medication. The blood pressure decreases when the client is sleeping; the medication usually is prescribed to be administered earlier in the day. The medication should be taken with food. No OTC medication should be taken without consulting the prescribing healthcare provider; decreased or increased effects can occur when there is an interaction with another medication.

A client with a history of pulmonary emboli is taking warfarin daily. The nurse teaches the client about foods that are appropriate to consume when taking this medication. The nurse evaluates that the client needs further teaching when the client makes which statement?

"Dark green leafy vegetables are high in vitamin K so I should eat them more often." Rationale: Foods high in vitamin K should be limited to the usual amounts eaten by the client when establishing the prothrombin time/international normalized ratio (PT/INR) because vitamin K is part of the body's blood-clotting mechanism and will counter the effects of warfarin if eaten in excess. Foods containing protein, iron, vitamin A, and iodine are permitted because they are unrelated to blood clotting.

A nurse is administering 40 mg of furosemide (Lasix) intravenously. Which sensation reported by the client does the nurse consider when determining that it is being administered too quickly?

"Ears are buzzing." Rationale: Rapid administration of furosemide can cause tinnitus (a perceived ringing or buzzing in the ears), loss of hearing, and ear pain. Lasix has a diuretic effect; urinary retention does not occur. Lasix does not affect the heart rate. Lasix does not cause peripheral neuropathy.

The nurse provides discharge medication education to a client who has been switched from a prescription for heparin to a prescription for warfarin sodium. Which client statement indicates to the nurse that teaching was effective?

"I will avoid taking aspirin and NSAIDs." Rationale: Acetaminophen should be used when an analgesic is required because it does not interfere with platelet aggregation. Acetylsalicylic acid (aspirin) should be avoided because it interferes with platelet aggregation. Immobility causes venous pooling and can predispose the client to deep vein thrombosis. Antibiotics are not necessary when going to the dentist; this is done when clients have cardiac problems, such as rheumatic fever or cardiac surgery. A prothrombin time (PT) or international normalized ratio (INR), not a complete blood count, needs to be done periodically.

The client who takes furosemide and digoxin reports that everything looks yellow. How will the nurse respond?

"I will hold the medication until I consult with your healthcare provider." Rationale: The response "I will hold the medication until I consult with your healthcare provider" is a safe practice because yellow vision indicates digitalis toxicity. The response "This is related to your heart problems, not to the medication" is incorrect; yellow vision is not a symptom of heart disease. The response "It is a medication that is necessary, and that side effect is only temporary" is incorrect; yellow vision is not a temporary side effect. The response "Take this dose, and when I see your healthcare provider I will ask about it" is unsafe.

what is angina? what are the two types of angina?

Crushing chest pain happening with activity and goes away with rest/predictable (stable) OR intense occurring at rest (unstable).

A patient comes in with persistent restlessness, dizziness and hypotension since he started taking amlodipine. He states he takes his medication with his grapefruit juice every night before bed. What patient education is needed.

DO NOT drink grapefruit juice while on a calcium channel blocker. Rationale: grapefruit juice increases effects of the drug.

What is significant about carvedilol?

Dec PVR ....while preventing reflexive tachycardia by blocking Beta 1 AND 2.

A client with heart failure is digitalized (given a loading dose of digoxin) and placed on a maintenance dose of digoxin 0.25 mg by mouth daily. What responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved?

Diuresis and decreased pulse rate Rationale: Digoxin slows the heart rate, which is reflected in a slowing of the pulse; it also increases kidney perfusion, which promotes urine formation, resulting in diuresis and decreased edema. Digoxin will decrease, not increase, the blood pressure; digoxin does promote weight loss through diuresis. Although digoxin produces diuresis as a result of improved cardiac output, which increases fluid output, it does not regulate an irregular pulse. Digoxin will not correct a heart murmur or decrease the pulse pressure.

A nurse is getting ready to administer Lasix how should she prepare?

Ensure method of urination is in place (empty foley, bedpan, urinal, commode, etc.) Rationale: Lasix is potent. Takes approx *5 mins* to begin working

A nurse attempts to give a client with chronic arterial insufficiency of the legs the prescribed dose of aspirin (ASA). The client refuses it, stating, "My legs are not painful." Which action by the nurse is appropriate?

Explain the reason for the medication and encourage the client to take it Rationale: Aspirin is given to the client to prevent platelet aggregation and possible deep vein thrombosis. The client needs information to make an educated decision. Aspirin is not prescribed to relieve pain. The client should receive information and support before making the decision to refuse the medication. Clients should never be pressured to take medication, especially when they do not have an understanding of the risks and benefits of the medication.

Name the loop diuretic medication discussed in this powerpoint

Furosemide ("Lasix")

A pt with heart failure has developed crackles in their lungs. Which medication would best treat this?

Furosemide (Lasix)

signs and symptoms of angina in women

GI upset, burning chest wall, overwhelming fatigue

Your patient with gout is scheduled to take HCTZ this afternoon. What should the nurse be mindful of?

HCTZ can increase uric acid thus worsening gout.

What should HDL and LDL cholesterol levels be?

HDL = high LDL = low

Mannitol should be used with caution in patients with...

HF signs of FVO Rationale: ???

Adverse reaction to consider with heparin

HIT (heparin induced thrombocytopenia)

What is the first line hyperlipidemic?

HMG-CoA Reductase Inhibitors (-statin)

Which diuretic is useful for mild to moderate HTN?

Hydrochlorothiazide (HCTZ) Rationale: decreases BP by 10-20

A client is taking furosemide. At each clinic visit, the nurse should assess for what adverse effect?

Hyporeflexia Rationale: Furosemide enhances the excretion of potassium, producing signs and symptoms of hypokalemia, such as hyporeflexia. Rapid weight loss, xanthopsia, and bronchospasm are not side effects of furosemide.

A client is admitted to the cardiac care unit with an anterior lateral myocardial infarction. The healthcare provider prescribes 500 mL of D5W with 50 mg of nitroglycerin to be administered intravenously to relieve pain. The nurse should assess for which most common side effect of this medication?

Hypotension rationale: The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure. Nausea is not a common side effect of intravenous nitroglycerin. Syncope is an infrequent effect when nitroglycerin is given intravenously. Reflex tachycardia may occur with the decrease in blood pressure.

A healthcare provider prescribes simvastatin 20 mg daily for elevated cholesterol and triglyceride levels for a female client. Which is most important for the nurse to teach when the client initially takes the medication?

Inform the healthcare provider if the client wishes to become pregnant. Rationale: Simvastatin is contraindicated in pregnancy because it is capable of causing fetal damage (teratogenic). It is a pregnancy category X teratogen. Simvastatin should be taken in the evening because most cholesterol is synthesized between midnight and 3:00 AM. Liver function tests should be done at 6 to 12 weeks initially and only then every 6 months. Although wearing sunscreen should be taught, sensitivity reactions are a rare occurrence and this is not as important.

Why do ace inhibitors have a side effect of increased potassium?

It acts on the RAAS system to inhibit aldosterone thus increased K+ Rationale: aldosterone and Vit K work inadvertently

A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day?

Maintaining potassium levels Rationale: Orange juice is an excellent source of potassium. Furosemide promotes excretion of potassium, which can result in hypokalemia. Digoxin toxicity can occur in the presence of hypokalemia. Neither drug increases sodium levels. Digoxin does not potentiate the action of furosemide; therefore, the client should not experience dehydration. Orange juice will not prevent an interaction between digoxin and furosemide.

Which nursing interventions are important when caring for clients receiving IV digoxin? Select all that apply.

Monitor the heart rate closely Check the blood levels of digoxin Monitor the serum potassium level Rationale:Bradycardia or other dysrhythmias may occur; therefore, the heart rate and rhythm should be monitored. ECG monitoring should be continuous. The digoxin level is checked before administration to avoid toxicity. A low serum potassium level when digoxin is administered can contribute to toxicity. Digoxin should be given over a 5-minute period through a Y-tube or three-way stopcock. There are many syringe, Y-site, and additive incompatibilities; the manufacturer recommends that digoxin not be administered with other drugs.

What is important to teach with taking -statins.

NO grapefruit juice with these meds

A healthcare provider prescribes digoxin for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity?

Nausea Rationale: Nausea and loss of appetite are the first indications of toxicity in approximately 50% of clients who take a cardiac glycoside, such as digoxin. Urticaria is a rare, not common, manifestation of digoxin toxicity. Photophobia is a later, not early, manifestation of digoxin toxicity. Yellow vision is a later, not early, manifestation of digoxin toxicity.

After teaching a family member how to administer subcutaneous enoxaparin sodium, how should a nurse evaluate the effectiveness of the training?

Observing the family member administering enoxaparin sodium to the client Rationale: The best way to evaluate the effectiveness of the teaching is to observe the family member administering the medication to the client. The family member may be able to perform a subcutaneous injection on a manikin but fear hurting the family member. Knowing the side effects of enoxaparin sodium is important, but it does not provide any information as to the family member's ability to administer the medication. The family member may be able to verbalize all the steps but fear puncturing the skin with the needle.

Warfarin is prescribed for the client who takes phenytoin for a seizure disorder. Why must the nurse observe the client closely during the initial days of treatment with warfarin?

Phenytoin decreases warfarin's anticoagulant effect. Rationale: Concurrent administration of phenytoin and warfarin can decease the anticoagulant effects of the warfarin. This interaction is the result of phenytoin causing increased metabolism of the warfarin by the liver. The nurse will need to monitor PT/INR values closely. Warfarin has been shown to inhibit (decrease) metabolism of phenytoin, not increase it. The action of warfarin is unchanged in patients with seizure disorder, as compared to patients without seizure disorder. Seizures do not have a significant effect on the metabolism of warfarin.

A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication?

Place the pill under the tongue and let it dissolve. Rationale: Sublingual medication is placed under the tongue and is quickly absorbed through the mucous membranes into blood. The buccal route requires placing medication between the cheek and gums. Chewing the pill and then swallowing it may be done for oral administration of some large size pills, but not with the sublingual route of administration. Taking the pill with water is required with the PO route of administration of medication, but not with sublingual. In addition, a full glass of water may be an excessive amount of fluid to swallow one pill.

What dietary choices should the nurse instruct the client taking spironolactone to avoid increasing? Select all that apply.

Potatoes Cantaloupe Rationale: Spironolactone is potassium-sparing, and therefore beverages and foods containing potassium such as potatoes, cantaloupe, bananas, avocados, oranges, dates, apricots, and raisins should not be increased beyond the client's ordinary consumption to prevent hyperkalemia. Red meat may need to be limited for other reasons not related to spironolactone. Whole grains are associated with prevention of constipation and should not be avoided. Dairy products are rich in sodium and calcium; spironolactone may cause hyponatremia.

A client with a partial occlusion of the left common carotid artery is to be discharged while still receiving warfarin. Which clinical adverse effect should the nurse identify as a reason for the client to seek medical consultation? Select all that apply.

Presence of blood in urine (hematuria). Vomiting coffee-ground emesis. Rationale: Warfarin causes an increase in the prothrombin time and international normalized ratio (INR) level, leading to an increased risk for bleeding. Any abnormal or prolonged bleeding must be reported, because it may indicate an excessive level of the drug. Common side effects including bruising, delayed clotting and bleeding gums do not require immediate intervention. However, hematuria and hemoptysis are evidence of more serious bleeding and require immediate attention. Coffee-ground emesis is a sign of gastric bleeding. Even though the emesis is not bright red, it still requires immediate attention by a healthcare provider.

The primary action of heparin is to:

Prolong coagulation time

Before you let your nursing student administer IV lasix you educate them that they should....

Push slowly...no faster than 10-20mg/min because lasix is ototoxic

Your 6 month pregnant patient has developed HTN. The doctor orders captopril. What is the nurses action?

Question order Rationale: Ace inhibitors should not be given to pregnant women.

What can happen if antihypertensives are stopped abruptly?

Rebound effect

A client with a history of hypertension comes to the emergency department with double vision and a blood pressure of 260/120 mm Hg. The healthcare provider prescribes a sodium nitroprusside infusion. The nurse recalls that sodium nitroprusside decreases blood pressure by what mechanism?

Relaxing arterial smooth muscles Rationale: This drug decreases blood pressure by relaxing venous and arteriolar smooth muscles and is used for immediate reduction of blood pressure. This drug may increase the heart rate as a response to vasodilation. It decreases cardiac workload by decreasing preload and afterload. It decreases peripheral resistance by dilating peripheral blood vessels.

Which of the following is an example of a potassium-sparing diuretic?

Spironolactone

Potassium sparing diuretics

Spironolactone (Aldactone)

2. The primary action of erythropoietin(Epogen) is:

Stimulates RBC production

Your patient presents to ER with itchy swollen rashes all over her face especially around her eyes and lips. Patient history states she is taking enalapril. Why is this significant and what should be done.

These are signs and symptoms of angioedema. Pt needs a new medication because she is having and *adverse rxn* to the ace inhibitor.

T/F: HCTZ can elevate glucose levels.

True

What is the antidote for warfarin

Vitamin K

A client who is immunosuppressed is receiving filgrastim. When monitoring effectiveness, the nurse will check for an increase in which blood component?

WBCs Rationale: Filgrastim, a granulocyte colony-stimulating factor, increases the production of neutrophils with little effect on the production of other blood components. The production of platelets is not stimulated by filgrastim. The production of erythrocytes is not stimulated by filgrastim. The production of thrombocytes is not stimulated by filgrastim.

When administering mannitol the nurse should use....

a filter on IV tubing Rationale: mannitol crystallizes

Your patient with HTN comes to his check up with complaints of new persistent dry cough. After assessing patient history you notice that he is taking lisinopril. What can be indicated? What orders should be expected?

an ace inhibitor side effect is dry cough and can be annoying. The nurse should anticipate orders for an ARB (-sartan)

What are all the side effects of ace inhibitors (-pril)?

angioedema dry cough taste disturbances Increased Vit K

What are *cautions* with beta blockers?

asthma/COPD (broncho constricts) diabetes (hypoglycemia) renal disorders

Nonvasodilating beta blockers and their side effects

atenolol metoprolol propranolol SE: weight gain. blood sugar problems

What of the following medications decrease cardiac workload by decreasing heart rate?

beta blockers

What is angina treatment

beta blockers calcium channel blockers nitrates *"MNA-B"* (morphine, nitro, aspirin, beta blocker)

Your type 2 diabetic patient has been newly diagnosed with HTN and prescribed metoprolol. What is the nurses concern with this scenario?

beta blockers can *masks* hypoglycemia Rationale: beta blockers can mask effects hypoglycemia effects so the patient will not feel hypoglycemic

Bile Acid Sequestrants work by:

binds with bile acids and then is excreted in stool

Women specific increased potassium symptoms

breast tenderness hirsutism menstrual irregular

Uses for mannitol

cerebral edema IICP hypoperfused kidneys

A herbalist is being prescribed cholestyramine. What should you notify this patient?

cholestyramine (questran) can impact vitamin absorption

Which of the following is an anti-platelet?

clopidogrel (Plavix) & aspirin

What is special about IV nitro

cover because it degrades in light

What is the duty of fibrates

decrease formation of triglycerides

Men specific increased potassium symptoms

decreased libido erectile dysfunction gynecomastia

What is HIT? What are the signs and symptoms?

decreased platelets in blood skin warm, SOB, skin tender

What effects do calcium channel blockers have on the heart?

decreases afterload decreases workload decreases peripheral resistance

What is the job of altepase?

dissolve clots

What should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopidogrel?

epistaxis Rationale: The high vascularity of the nose, combined with its susceptibility to trauma (e.g., sneezing, nose blowing), makes it a frequent site of hemorrhage. Nausea, chest pain, and elevated temperature usually are not associated with anticoagulant therapy.

It is safe to give nitroglycerin to a patient also taking sildenafil (Viagra).

falls

Supplements that impact coagulation

feverfew green tea ginkgo fish oil ginger garlic

what is significant about ARBs?

few side effects.... Rationale: only side effects are hypotension related

Name 2 Fibrates

gemfibrozil fenofibrate

Which of the following supplements can interfere with coagulation?

ginger

How should the patient take a nitro when experiencing angina?

give SL tab q5mins 3 times

What are sources of vitamin K

green leafy veggies Rationale: patients should not change what/how they eat. Maintain eating habits.

What is the most common side effect of nitroglycerin?

headache

What are side effects for statins

headache fatigue heart burn rhabdomyolysis (life threatening)

Prior to giving digoxin, you get a full set of vital signs. Which vital sign would indicate the med needs held?

heart rate below 60

Patient ask "how long does it take for heparin to melt my clots?" How do you respond?

heparin does not dissolve clots it prevents production of clots

Name the thiazide medication discussed in the powerpoint

hydrochlorothiazide (HCTZ)

Gemfibrozil (Lopid) is the first-line drug for the treatment of:

hypertriglyceridemia

What are general side effects to be expected with antihypertensives?

hypodizziness syncope lightheadedness orthostatic hypotension

What type of electrolyte imbalance can occur with digoxin and diuretics?

hypokalemia

Heparin onset..

immediate

Where and how is Enoxaprin (Lovenox) administered

in the abd rotate sites and do not rub after administration

The desired effect of Filgrastim ( Neupogen) is:

increased neutrophil count

What is the risk with spironolactone

increased potassium Rationale: Potassium is held onto and sodium is pushed out

What is Lasix effects on potassium?

lowers potassium Rationale: loop diuretics dump potassium along with sodium and water

Signs of increased potassium

muscle weakness palpitations cramping diarrhea

What is the first-line drug for acute angina?

nitro

Nitro is contraindicated in...

patients taking viagra

How is Cholestyramine administered?

powder mixed with fluid *DO NOT take with meals take with fluid*

What is the heparin antidote?

protamine sulfate

What is used as the antidote for heparin?

protamine sulfate

A pt with COPD is being started on metoprolol for HTN. Which response by the nurse is the priority?

questioning order

What is the job of calcium channel blockers?

relaxes coronary artery and peripheral arterioles

Complaints of muscle and joint pain after starting a statin could indicate which condition?

rhabdo

Name the potassium sparing medication discussed in the powerpoint

spironolactone (aldactone)

What can the patient do to prevent GI upset with taking fibrates

take medication with meals

While watching a nursing student apply nitro paste on patient what should you ensure?

that the student is wearing gloves Rationale: nitro can cause headaches

What is rhabdomyolysis

the breakdown of muscle tissue releases muscle fiber contents into the blood. these substances can cause kidney damage

Why might warfarin and heparin be given together?

timing....Warfarin takes days to work while heparin is immediate. Once warfarin reaches effect we can stop heparin.

An important nursing consideration in the administration of Mannitol is:

use a filter

What do alpha blockers do to the body?

vasodilates vessels

What are 2 other CCBs mentioned in PowerPoint?

verapamil diltiazem

Which of the following is a symptom of digoxin toxicity?

vision disturbance