A patient has been taking digoxin at home but took an accidental overdose and has developed toxicity. The patient has been admitted to the telemetry unit, where the physician has ordered

Correct Answer: B

Rationale: The correct response is to inform the patient that the medication, likely an antiarrhythmic agent such as digoxin immune fab (Digibind), helps to convert the irregular heart rhythm caused by digoxin toxicity to a more normal rhythm. This explanation provides a clear understanding of why the medication is being administered in cases of digoxin toxicity. It is important for the nurse to educate the patient about the purpose of the medication and how it will help manage the symptoms of digoxin toxicity.

Correct Answer: C

Rationale: A common side effect of Heparin, which is an anticoagulant medication, is the risk of bleeding. Heparin works by preventing the formation of blood clots, which can lead to a bleeding risk as it inhibits the normal clotting process. Patients taking Heparin should be monitored closely for signs of bleeding, such as easy bruising, prolonged bleeding from minor cuts, or blood in the urine or stools. It is important for healthcare providers to closely monitor patients on Heparin therapy and adjust the dosage as needed to minimize the risk of excessive bleeding.

Correct Answer: D

Rationale: It is important to monitor ins and outs with patients using ACE inhibitors to assess for decreased blood pressure. ACE inhibitors are known to lower blood pressure by dilating blood vessels, which can sometimes lead to hypotension (low blood pressure). Monitoring the patient's fluid intake and output helps healthcare providers evaluate the patient's blood pressure response to the medication and make necessary adjustments to prevent complications such as dizziness, falls, or fainting. Regular monitoring is crucial to ensure the patient's safety and optimize the effectiveness of ACE inhibitor therapy.

Correct Answer: C

Rationale: Heparin is an anticoagulant medication that works by preventing the formation of blood clots. One of the main side effects of heparin therapy is an increased risk of bleeding. Since heparin inhibits the body's ability to clot blood, it can lead to easy bruising, nosebleeds, gastrointestinal bleeding, or bleeding at the injection site. Patients on heparin therapy must be closely monitored for signs of bleeding, and their dosage may need to be adjusted to minimize this risk.

Correct Answer: A

Rationale: ACE inhibitors, such as enalapril and lisinopril, work by blocking the enzyme angiotensin-converting enzyme (ACE), which is responsible for converting angiotensin I into angiotensin II. By inhibiting this conversion, ACE inhibitors prevent the vasoconstrictor and aldosterone-stimulating effects of angiotensin II at the receptor sites. This leads to vasodilation, decreased blood pressure, and reduced aldosterone secretion. This mechanism of action makes ACE inhibitors an important class of medications for managing conditions such as hypertension, heart failure, and chronic kidney disease.