The client asks about side effects of taking digoxin. How does the nurse respond?

Correct Answer: A

Rationale: The correct answer is A: Anorexia can be a side effect of digoxin. Digoxin is known to cause anorexia due to its impact on the gastrointestinal system. It can lead to nausea, vomiting, and loss of appetite, resulting in anorexia. Tachycardia (choice B) is not a common side effect of digoxin, as it is actually used to treat certain types of arrhythmias. Constipation (choice C) and urinary retention (choice D) are also not typically associated with digoxin use. In summary, anorexia is a known side effect of digoxin, while tachycardia, constipation, and urinary retention are not commonly linked to this medication.

Correct Answer: C

Rationale: The correct answer is C: Seizures. Lidocaine is a local anesthetic that can cause central nervous system toxicity, leading to seizures. This is the most concerning side effect because it can be life-threatening. Severe headache (A) is not typically associated with lidocaine toxicity. Nausea and vomiting (B) are common side effects but not the most concerning. Tremors (D) can occur but are not as serious as seizures in this context.

Correct Answer: A

Rationale: The correct answer is A: Administer vitamin K as an antidote. An INR of 5.5 indicates the client is at risk for bleeding due to excessive anticoagulation from warfarin. Administering vitamin K helps reverse the effects of warfarin and lowers the INR back to the therapeutic range. Holding the next dose of warfarin (B) is important but not the priority over administering the antidote. Increasing the dose of warfarin (C) would worsen the situation. Administering fresh frozen plasma (D) is not a standard treatment for high INR levels due to warfarin.

Correct Answer: B

Rationale: The correct answer is B: Check the client's blood pressure. When administering a beta blocker to a client with hypertension, the priority assessment is to check the client's blood pressure. Beta blockers lower blood pressure, so monitoring it before administration helps ensure it is within the safe range. Checking the client's heart rate (choice A) is important but not the priority in this scenario. Respiratory rate (choice C) and temperature (choice D) are not directly related to the administration of beta blockers for hypertension.

Correct Answer: A

Rationale: The correct answer is A: Foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Consuming foods high in potassium while on spironolactone can lead to hyperkalemia, which is an elevated level of potassium in the blood. This can result in serious health complications such as irregular heartbeats and muscle weakness. Therefore, it is crucial for clients on spironolactone to avoid foods high in potassium to prevent these adverse effects. Choices B, C, and D are incorrect because spironolactone does not specifically interact with sodium, calcium, or chloride in a way that necessitates avoiding foods high in these electrolytes.