Karch MOdule 3
A client admitted with digitalis toxicity has taking the same dose for more than 10 years. What question should the nurse ask to assess for the possible cause of the increased serum level of the medication?
"Do you take regular doses of antacids?" Explanation: Decreased absorption of digoxin can result in digoxin toxicity or digitalis toxicity. Factors that decrease the absorption of digoxin include the presence of food in the GI tract, malabsorption syndromes, and the concurrent administration of antacids or cholestyramine. The administration of digoxin should take place at least 1 hour before the administration of an antacid. An accumulation of digitalis in the body can lead to nausea, vomiting, visual disturbances, atrial or ventricular tachydysrhythmias, ventricular fibrillation, sinoatrial block, and AV block.
Digoxin has been prescribed for an outclient with symptomatic heart failure. What is the priority teaching point to convey to this client?
"Make sure to take your pulse for a minute before taking your digoxin." Explanation: Clients should measure their heart rate for a full minute before taking a dose of digoxin. The drug can be taken with food, and potassium intake should be increased, not decreased. The client's daily dose of digoxin should never be increased in response to short-term changes in symptoms.
A male client who is prescribed digoxin asks the nurse how he should take the drug. Which instruction would be most appropriate?
"Take the drug on an empty stomach at the same time each day." Explanation: Food and antacids interfere with the absorption of the drug. Digoxin should be taken on an empty stomach at approximately the same time each day. If the client takes an antacid, the client should separate the dose of antacid and digoxin by 2 to 4 hours.
The nurse identifies the therapeutic range for digoxin as:
0.8 to 2 ng/mL. Explanation: Therapeutic digoxin levels are between 0.8 and 2 nanograms/mL. Plasma digoxin levels greater than 2 nanograms/mL are considered toxic.
A patient is receiving milrinone IV. The nurse would administer the bolus over which time frame?
10 minutes Explanation: Milrinone is administered by IV bolus over 10 minutes.
A nurse obtains the serum digoxin level and immediately reports a level greater than which value?
2.0 ng/mL. Explanation: A nurse must immediately report serum digoxin levels greater than 2.0 ng/mL. Therapeutic drug levels are between 0.8 and 2 ng/mL.
A nurse caring for a patient with atrial fibrillation who is started on digitalis is required to monitor plasma digitalis levels in the patient's blood. Which plasma level of digitalis indicates that the nurse should report to the practitioner?
2.2 ng/ml Explanation: A plasma digitalis level of more than 2 ng/ml would require the nurse to report to the practitioner; therefore plasma digitalis levels of 2.2 ng/ml indicate digitalis toxicity. In such circumstances, the nurses should immediately report to the practitioner. The therapeutic levels of plasma digitalis are 0.5 to 2 ng/ml.
A client experiences nausea and visual disturbances when taking digoxin (Lanoxin). The nurse would anticipate the client's digitalis level to be:
2.7 nanograms/mL Explanation: Therapeutic drug levels of digoxin are between 0.8 and 2 nanograms/ mL. Plasma digoxin levels greater than 2 nanograms/mL are considered toxic and the client may experience signs and symptoms of toxicity.
A male client states that he is seeing halos around lights. The client takes digoxin (Lanoxin) by mouth every day. The health care provider orders the client to have serum digoxin level drawn. Which of the digoxin levels indicate the client is experiencing toxicity?
4.0 nanograms per milliliter Explanation: Therapeutic serum levels of digoxin are 0.5 to 2 nanograms per milliliter; toxic serum levels are above 2.0.
A nurse is administering digoxin intravenously as ordered. The nurse would administer the drug over which time frame?
5 minutes Explanation: Intravenous digoxin must be administered slowly over at least 5 minutes to prevent cardiac arrhythmias and adverse effects.
After receiving a loading dose of milrinone (Primacor), what is a client most likely to experience? (Select all that apply.)
Angina Headache Explanation: The adverse reactions most likely to occur after the administration of milrinone (Primacor) to a client are ventricular arrhythmias, hypotension, angina, chest pain, and hypokalemia.
What is the most accurate method for preventing adverse effects associated with the use of digoxin?
Assess the client's heart rate and hold administration if it is less than 60. Explanation: Clients should be taught to hold their digoxin if their heart rate is less than 60 (or some other defined heart rate). Divided doses are not normally used and an awareness of heart failure does not preclude adverse effects of digoxin.
A female client presents to the emergency department with nausea, vomiting, and a heart rate of 45 beats per minute. Her husband states that she takes digoxin, Lasix, and nitroglycerin for chest pain. Laboratory results confirm digoxin toxicity. The nurse would expect the health care provider to order what medication to treat the bradycardia?
Atropine Explanation: Atropine or isoproterenol, used in the management of bradycardia or conduction defects, may be administered to clients with digoxin toxicity.
When caring for a patient who has been digitalized for his heart failure, the nurse observes that the patient is experiencing bradycardia. Which drug should be administered to patients who develop bradycardia?
Atropine Explanation: Atropine should be administered to patients who develop bradycardia. Bradycardia may be seen in digitalis toxicity. Inamrinone and milrinone are miscellaneous inotropics used in heart failure. Cholestyramine is used to lower blood cholesterol levels. Inamrinone, milrinone, and cholestyramine are not used in the treatment of bradycardia.
A nurse is caring for a patient admitted to the intensive care unit because of heart failure. The patient is prescribed digoxin. Which nursing diagnosis would be appropriate for this patient?
Decreased Cardiac Output related to altered cardiac function Explanation: Use of digoxin increases the risk for Decreased Cardiac Output related to altered cardiac function from the drug therapy. The use of digoxin does not pose a risk for acute pain, headache, hyperthyroidism, or constipation.
A nurse is planning an in-service program for a group of staff nurses about heart failure and its treatment. The nurse would identify which agent as the most commonly used drug for treatment?
Digoxin Explanation: Digoxin is the drug most often used to treat heart failure. Human B-type natriuretic peptide, ACE inhibitors, or hydrochlorothiazide also may be used, but these drugs are not the most common ones used.
After teaching a class of students about heart failure and drug therapy, the instructor determines that the teaching has been successful when the students identify which drug as most often used as treatment?
Digoxin Explanation: Digoxin is the drug most often used to treat heart failure. Human B-type natriuretic peptide, nitrate, or furosemide also may be used, but these drugs are not the ones most commonly used.
A 58-year-old man is admitted to the emergency department. A diagnosis of severe digoxin toxicity is made. Bradycardia is present, and an electrocardiogram (ECG) confirms toxicity. The nurse will administer which drug?
Digoxin immune fab Explanation: Digoxin immune fab is used as the antidote to digoxin toxicity. The other drugs would not be used to treat digoxin toxicity. The patient could be taking furosemide as part of the drug regimen for heart failure.
A male client is diagnosed with heart failure. The health care provider orders a loading dose of digoxin. Loading doses are necessary for what reason?
Digoxin's long half-life makes therapeutic serum levels difficult to obtain without loading. Explanation: Digoxin dosages must be interpreted with consideration of specific client characteristics, including age, weight, gender, renal function, general health state, and concurrent drug therapy. Loading or digitalizing doses are necessary for initiating therapy, because digoxin's long half-life makes therapeutic serum levels difficult to obtain without loading. Loading doses should be used cautiously in clients who have taken digoxin within the previous 2 or 3 weeks.
A 65-year-old client presents to the health care provider's office with reports of shortness of breath on exertion, edema in the ankles, and waking up in the middle of the night unable to breathe. The nurse suspects that the symptoms are indicative of which condition?
Heart failure Explanation: Cardinal manifestations of HF are dyspnea and fatigue, which can lead to exercise intolerance and fluid retention resulting in pulmonary congestion and peripheral edema.
The pharmacology instructor is discussing cardiac glycosides with a class of pre-nursing students. According to the instructor, what physiologic effect do cardiac glycosides trigger?
Increased force of heart contraction Explanation: Cardiac glycosides increase the force of cardiac contraction, which increases cardiac output.
A nurse is preparing to administer inamrinone. The nurse would administer this drug most likely by which route?
Intravenous Explanation: Inamrinone is administered only by the intravenous route.
Milrinone (Primacor) is a miscellaneous inotropic drug used in the short-term management of heart failure. What is the only way this drug is approved to be administered?
Intravenously Explanation: Milrinone (Primacor) is only to be given intravenously. The other routes are not used.
The client's digoxin level is 0.125. How does the nurse interpret this level?
Low Explanation: The normal digoxin level is 0.5 to 2.0 ng/mL. Serum levels greater than 2 ng/mL are toxic; however, toxicity may occur at any serum level.
The nurse is caring for a patient receiving cardiotonic drugs. The patient has edema. Which intervention should be taken to alleviate edema?
Measurement of intake and output Explanation: Measurement of intake and output is a nursing intervention related to the edema in the patient receiving cardiotonic drugs. Auscultation of the lungs, observation of respiratory rate, and observation of pulse rate are interventions not related to edema in the patient.
The nurse is preparing to administer digoxin to a 9-month-old infant. What must the nurse do prior to administration of this medication?
Monitor the infant's apical pulse Explanation: The nurse must assess the client's apical pulse before administering digoxin because it has a narrow therapeutic index and can cause the heart rate to go too low, so the nurse takes the apical pulse and holds the medication if it is below a certain level (depending upon age of the client.)
The nurse is to administer digoxin to a client with heart failure. The nurse auscultates an apical pulse rate of 52. What action should the nurse take?
Notify the health care provider Explanation: Before administering each dose of digoxin, take the apical pulse rate for 60 seconds. If the apical rate is below 60 beats per minute, withhold the drug and notify the provider. Blood pressure is not affected by digoxin. Without prescriptive authority, the nurse cannot change medication dosages.
A nurse is caring for a 66-year-old female client who is receiving digoxin. When preparing to administer a dose, the nurse observes that the client's apical pulse rate is 55 bpm. What is the appropriate action to take?
Omit the dose and contact the health care provider. Explanation: Bradycardia is a potential adverse effect of digoxin. Nurses should assess the client's apical pulse before each dose. If the rate is lower than 60 bpm in an adult client, the nurse should omit the dose and notify the provider.
Which would a nurse expect to assess if a client is experiencing right-sided heart failure?
Peripheral edema Explanation: Peripheral edema would be noted in clients with right-sided heart failure. Wheezing, hemoptysis, and dyspnea would suggest left-sided heart failure.
The pharmacology instructor is describing medications that increase the contractile force of the heart. Which term describes this effect?
Positive inotropic Explanation: A positive inotropic effect improves the contractility and pumping ability of the heart.
A patient with congestive heart failure has been digitalized. The patient requires long-term digoxin therapy. Which instructions should the nurse provide the patient on discharge?
Take the drug regularly without skipping a dose. Explanation: The nurse should instruct the patient to take the drug regularly without skipping a dose. The patient should consult the provider before discontinuing the drug. Taking the drug with high-fiber meals will decrease the absorption of the drug. The patient should be advised to report to the center if the pulse is less than 60 bpm. Antacids should not be taken as it alters the plasma digoxin levels.
A client has an elevated BUN. The client has been prescribed digoxin for heart failure. What aspect of care is the priority regarding this client?
The dose should be decreased in this client. Explanation: The dose must be reduced in the presence of renal failure because most of the digoxin is excreted unchanged by the kidneys, leading to drug accumulation and toxicity. The client should be taught to limit sodium intake in the diet. The client's heart rate should remain above 60. If the heart rate falls below 60, the digoxin should be held. The dose of 1.0 mg is too large for a client with altered renal function.
Vasodilators used to treat heart failure include nitrates and ACE inhibitors.
True Explanation: Drug therapies used to treat heart failure include vasodilators, such as angiotensin-converting enzyme (ACE) inhibitors and nitrates, which decrease cardiac workload, relax vascular smooth muscle to decrease afterload, and allow pooling in the veins, thereby decreasing preload of the heart and helping to improve function.
A nurse assessing a client on digoxin suspects toxicity. Which visual disturbances would the nurse expect to assess?
Yellow or green vision Explanation: The visual disturbance the nurse should assess for is yellow or green vision with a white halo. Visual disturbances occur in digoxin toxicity. Blurring of vision and borders around dark objects are the other visual disturbances. Double vision, difficulty of near vision, and complete loss of vision do not occur in digitalis toxicity.
A client is receiving digoxin and experiences severe bradycardia. Which medication would the nurse anticipate administering if prescribed?
atropine Explanation: If severe bradycardia occurs, atropine may be ordered. Milrinone is a miscellaneous inotropic drug used to treat heart failure. Activated charcoal is an antidote for poisoning with certain toxic substances, but not digoxin. It also decreases serum digitalis levels. Propafenone increases serum digitalis levels and would not be used.
What assessment should the nurse perform on a daily basis when a client is prescribed furosemide?
body weights Explanation: When a client is being treated with furosemide, the nurse weighs the client daily and reports any increase in weight of greater than 2 lb (0.9 kg) in 24 hours to the health care provider. Electrolyte levels must be assessed, but sodium and potassium levels are the priority. There is no particular need to assess ABGs or pupillary response.
A client is being treated for heart failure. Which is most indicative of improved health status?
decreased pitting edema Explanation: The absence of pitting edema, decreased size of ankles and abdominal girth, and decreased weight improves circulation and increases renal blood flow. The diminished fluid volume is indicative of an improved blood supply to the body tissues. Increased skin turgor indicates that the client is well hydrated and does not have fluid volume excess. A heart rate of 52 is too slow to provide good contractility. Improved sensorium indicates adequate perfusion but is not the most indicative of improved heart failure status.
A client being treated for hypokalemia has a medication history that includes propranolol, digoxin, and warfarin. When the client reports nausea, abdominal discomfort, and visual changes, the nurse suspects what as the causative factor?
digitalis toxicity Explanation: People diagnosed with hypokalemia can develop digitalis toxicity even when digoxin levels are not considered elevated. Signs of toxicity include potentially life-threatening heart rhythm disturbances, ranging from very slow to rapid ventricular rhythms. Other side effects include nausea, vomiting, loss of appetite, abdominal discomfort, blurred vision, and mental changes. The situation described does not support the conclusion that any of the other options are responsible for the client's described symptomology.
The client has crackles in the lower lobes of the lungs, an audible S3, and pitting edema in the feet and ankles. What condition is the client most likely experiencing?
heart failure Explanation: The cardinal manifestations of heart failure are dyspnea and fatigue, which can lead to exercise intolerance and fluid retention. Fluid retention results in the development of pulmonary congestion and peripheral edema. An audible S3 is often present. The client is not presenting with myocardial infarction symptoms since there is no mention of chest pain. Neither pneumonia nor liver failure would present with the audible S3 sound.
After teaching a group of students about conditions that can lead to heart failure, the instructor determines that additional teaching is needed when the students identify:
renal failure. Explanation: Renal failure would be least likely to contribute to the development of heart failure. Coronary artery disease, cardiomyopathy, valvular disease, and hypertension are commonly associated with heart failure.